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GPs face legal risk in rush to computerised records

The drive towards computerised record-keeping ­ set to gather pace under the new contract ­ is leaving GPs more vulnerable to legal action, warn leaders of a major study.

The switch from paper to IT-based records 'encourages minimalist record-keeping', leading to gaps in vital information on the duration and severity of key symptoms, the researchers found.

The two-year study, which compared the quantity and quality of computer and paper records in 18 practices, found a hybrid system worked best.

GPs using computer systems alone failed to make any record of one consultation in nine, with home visits most likely to be neglected. One in six consultations went unrecorded in practices using only paper systems, with telephone consultations most likely to be missed.

A retrospective analysis of 15,758 consultations with patients later diagnosed with cancer showed fewer symptom codes per consultation were recorded in computer notes (average 1.66) compared with paper (1.79).

The absence of key symptoms potentially associated with cancer was also much less likely to be recorded in computer notes.

The limited free text available on some computer systems, the lack of codes to record absent symptoms and the fact that GPs could not easily use shorthand to record symptom severity were all identified as obstacles to comprehensive record-keeping in a report in the British Journal of General Practice (December).

Study leader Dr William Hamilton, research fellow in primary care at the University of Bristol, said: 'High quality record-keeping may be essential for medicolegal purposes. If a consultation is unrecorded a doctor will have lost a major piece of evidence.'

Dr Karen Dalby, clinical risk manager at the Medical Defence Union, said its recent survey of 200 GPs found 39 per cent recorded less information in computer records than on paper, making claims potentially more difficult to defend.

Joint deputy GPC chair Dr Hamish Meldrum said the quality criteria for computer systems were being 'ratcheted up' and one aim was to make software 'user friendly enough to reflect nuances'.

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