Doctor Notes – Contemporaneous Notes
A doctor is considered to be a life savior, next only to God. Now imagine a scene like this, where a patient comes to a doctor for the treatment of minor fever and the administering doctor gave him the shot of a medicine that he is allergic to. He had consulted the notes which had patient’s medical history, but nowhere was it mentioned that the patient is allergic to anything. This results in a severe allergic reaction and finally he had to be admitted to the ICU. A patient trusts his or her life to a doctor, but sometimes due to simple negligence on a doctor’s part, the thin line between death and life may get blurred.
Doctors, though believed to have eidetic memory, cannot rely completely on their memory. In this scenario, efficient medical record keeping comes as a useful reminder of what had happened, the steps that were taken and the action that needs to be taken now. The notes should be self sufficient in providing information about the health of a patient and his past history, in case the patient has to change the doctor, or the doctor needs to update his other team members, or any other doctor needs to know the past history of the patient to continue providing care.
The General Medical Council of United Kingdom has guidance for Good Medical Practices, which states that the record of a doctor’s work should be clear, accurate and can be easily read. The records should be made at the same time as the event has occurred or as soon as possible after that. As the privacy of a patient is foremost, a doctor should keep such records that contain personal information about the patients in a secure place with as much protection as can be. They should be inaccessible to others and be protected against loss, corruption, damage or destruction. Good contemporaneous notes must include the date and time, but abbreviations should be not be used to avoid any ambiguity. The entries once made should not be altered and nothing should be added to the notes. In case wrong information is written in the record an update can be made at the bottom of the notes. The tampering with the records may lead to a legal investigation against the doctor.
While making contemporaneous notes, it is advised that unnecessary comments or opinions should be avoided. These notes should be written in a professional language and not include offensive, personal or humorous comments which may be misunderstood by the others and undermine your credibility. They may become difficult to explain in front of a medical panel or court of law. The notes should be checked once again after completing to see in case any entry has been missed or entered incorrectly. A doctor must evaluate these notes thoroughly before making final copy. These records should be maintained sequentially picking up from where they were left to avoid tampering or backdating. They should never be made in advance and words like ‘appears’, ‘apparently’, ‘may have’ should be avoided. They should only contain factual and objective information about the patient’s health.
These contemporaneous records should include, but not be limited to, the clinical findings that seem relevant, what decisions were made or agreed upon, who all were involved in the process of decision-making, was the information imparted to the patient, what drugs were prescribed. They also include comments on the progress or any peculiar findings while the treatment is on, what care and management plan will be followed, records of consent by the patient, situations where patient refused to be examined or undergo the recommended treatment, what information that the doctor wanted but could not get, who all were involved in the treatment, comments regarding opinions of the doctor, warning signs given to the patients in case medicine is taken. For e.g., there are a lot of illnesses that are not diagnosed to start with, but get developed quickly. In that case a small note in the records can be slipped in that diagnosis for that particular anomaly was not done as specific signs and symptoms could not be seen at that time. Such notes become very useful when case of negligence is filed against a doctor.In the case of McCave v. Auburn District Hospital, the patient was admitted for an emergency appendicectomy. He was not feeling better even after 5 days since surgery. The doctor ordered a full blood count, but the reports that showed severe infection were filed in the wrong section of the medical records by the registered nurse. She also forgot to notify about the report to the doctor, as a result of which the patient died. The severe case of negligence in handling the records by the nurse and the doctor was seen in an extremely bad light and the accused were punished.
A doctor is also expected to maintain the details of the telephonic conversations or exchange of emails with a patient. Such medical records maintained contemporaneously by a doctor are essential at multiple levels. They are important to be maintained while the treatment of a patient is on and also becomes a crucial piece of evidence in case there is any claim of breach of duty or for any litigation purpose. To avoid litigation or to make a strong case in your favor in a court, it is advisable to make good contemporaneous notes with each and every detail.Usually any complaint or claim that is filed against any doctor is done after months or years of consultation. In that case, these notes serve as a good reminder of the events, telling exactly how they took place, along with the date and time. While giving a testimony in the court, the doctor is allowed to refer to the contemporaneous notes to remember the event correctly. Any non-contemporaneous record is not allowed in the court of law. These notes will help a doctor to reconstruct the events and important parts of each meeting with the patient.
Apart from serving as a vehicle by which all the team members can communicate while directing the care and treatment of the patient and evidences in court of law, medical records can also be used for research purposes as educational tools. New way of maintaining contemporaneous records of a patient is coming up, which is electronic documentation. By maintaining the notes electronically, the doctor can do it anywhere, anytime. The chances of botching up the records is significantly lesser than maintaining paper records as every patient will be allotted particular number with the help of which his or her records can be searched and updated. This provides ease in accessing and searching the records, as well as, automatic time-stamping. Hence, these records would serve as authentic evidence in the court. Also these records can be retained forever, if the need be. In case of technology failure, regular back-ups should be made.
Contemporaneously created medical records of a patient by a doctor can only be shared with the patient and the courtm, police or insurance company in case the need arises, only with patient’s consent. The patient must be made fully aware of the sensitive information.
Inappropriate contemporaneous notes by a doctor show that he/she is not able to perform his/her duties correctly and is not in a position to take appropriate decisions about patient care. Like they say, “No notes, no defense”. Poorly maintained medical records may have very severe consequences and could lead to injuries and reactions. A doctor is expected to record even negative findings and drug allergies or adverse reaction. They should note down the risks and benefits of certain proposed treatment, genetic history of the patient’s family members, results of investigation and tests or any information that tells about the patient’s path and current clinical assessment.In the Javis v. St. Charles Medical Centre (1996), the doctor had ordered hourly observations on the fractured leg of the patient. The initial observations were taken and recorded but after some time they became intermittent. Next day, the doctor saw that the patient’s foot was pulseless, white and painful. On checking the records it was found that the last record was taken four hours ago. Since there were no records, there were no observations. Hence, the court decided against the nursing staff and the hospital.
It becomes an inevitable task to maintain contemporaneous note, no matter how boring or tedious it may seem. All the records should be kept updated that means as soon as a doctor gets his hand on any information, he or she should add it to the patient’s notes. Medical personnel have professional and moral responsibilities to create and maintain accurate records about the care and treatment given to a patient.Hence, there cannot be a substitute for a decent contemporaneous record keeping.
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Essentials of law for Medical Practitioners. Retrieved from, https://books.google.co.in/books?id=otQvMaoagSUC&pg=PT71&lpg=PT71&dq=contemporaneous+notes+of+a+doctor&source=bl&ots=Eb3EGvxxWc&sig=DbCR6ENFu7ocxVbcB1D-2h_BT8w&hl=en&sa=X&ved=0CEYQ6AEwCGoVChMIhKv-5v6myAIVVpCOCh3apwSC#v=onepage&q=contemporaneous&f=false