In the unfortunate event of receiving a complaint, your clinical notes will be of great importance.
Not only of course, will they be available to the complainant and to wherever the complaint was made, but to their own medical advisors. In turn, those advisors will correlate your notes with the nature of the complaint and use your notes to judge whether your practice was appropriate. The problem of hindsight bias is self-evident.
When you write your notes, you would usually have no idea if a complaint were going to be made. So, what approach could you use that might provide better defence if a complaint was made, and that might also result in better patient care?
At least part of the answer lies in having foresight; thinking about what might lead to a complaint in advance. Remember that for all you will hear about the various drivers of complaints, at the top of the list is an adverse outcome of care - whether perceived or real is irrelevant.
Our advice at Medicus, is to consciously consider what an adverse outcome of care might look like, while you are writing your notes.
Note-writing is your time for reflection, for considering what happened during the consultation and what your actions (or omissions!) were. We do not advocate note-writing after the patient has left the consultation, because the opportunity for reflection-in-action is somewhat lost, and your opportunity to change the narrative risks slipping away.
The process for this reflection is straightforward. Firstly, as you write or review your notes (particularly if they are made using an Artificial Intelligence algorithm), consider what an HDC reviewer would look for. Is your diagnosis and management supported by the patient’s presentation, your inquiry, examination, investigations and so on? Mistakes do happen and taking a moment to double-check is time well spent.
Secondly, and this is the key to this article, take a moment to consider what an adverse outcome might look like in this case or situation. In other words, what is a worst-case scenario? Could this toddler with a sniffly nose have pneumonia or meningitis? Could this patient’s ‘indigestion’ be ischaemic heart disease?
These questions seem obvious as the sort of questions that we should all ask all the time, but you and I know that we don’t always do so. And if that worst-case scenario eventuates and results in a complaint, that lack of documented thought process will be exposed and make your defence that much more difficult.
Use your write-up as an opportunity for reflection. Consider the ‘correctness’ of your practice and let your mind drift for a moment to a potentially adverse outcome and whether what you’ve written demonstrates that you have considered that possibility, or that such an outcome is way outside the bounds of reasonable doubt for those circumstances.
Try this approach! Reflect and think ahead. It may save your life (and your patient’s).
Dr Wayne Cunningham
General Practitioner
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