Inaccurately transcribed records and their dangers
Dr Nicholas Norwell, MDU medicolegal adviser, stresses the importance of GPs taking every possible precaution to ensure the accuracy of patients' medical records
Inadvertent errors can occur in medical records for a number of reasons, but at the Medical Defence Union (MDU) we are aware of a number of recent complaints and claims where problems with transcribed notes created difficulties both for continuity of care and in defending members' actions.
In one case a GP working out of hours made paper notes of consultations, which a secretary later transcribed on to the computer system without the GP seeing them again. A medical negligence claim was made against the GP some years later but it proved difficult to defend the GP's actions because the transcribed notes were incomplete and inaccurate because of misunderstandings of medical terminology, the original paper notes had gone missing and the GP understandably could not recall the consultation.
Last year, Unison, the public services union, stated that inaccuracies had arisen in some records after audio files dictated by hospital doctors were outsourced to be typed by external companies overseas1.
Where patient care is increasingly being provided by multi-disciplinary teams it is important that other health professionals can rely on the accuracy of details of medication and treatment recorded in notes.
Paragraph 3 of Good Medical Practice (2006) states you must 'keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients and any drugs prescribed or other investigation or treatment'.
In addition, paragraph 65 states: 'You must do your best to make sure that any documents you write or sign are not false or misleading. This means that you must take reasonable steps to verify the information in the documents, and you must not deliberately leave out relevant information.'
GPs also have a contractual obligation2 to ensure that adequate records are kept of their attendance and treatment of patients. Additionally, the QOF3 requires practices to have 'a system for transferring and acting on information about patients seen by other doctors out of hours'.
The routine inputting of data, for example scanning documents such as hospital letters and results into a patient's electronic record, can safely by done by a trained non-clinician. However, the Good Practice Guidelines for General Practice Electronic Patient Records4 recommend that clinicians input their own data to reduce transcription errors and problems of legibility.
Wherever transcribing is being done remotely by a third party it is important for the doctor to check and sign every entry before it is added to a patient's notes. In Good Medical Practice, the GMC requires doctors to identify themselves clearly using their registered name when signing statutory documents. Doctors may also wish to include their GMC reference number alongside their signature so there is no doubt about who made the entry.
Where GPs are relying on clerical staff to do the transcribing they have a duty to ensure that those staff are trained and competent. It is also important to record all consultations, such as phone calls, home visits and contacts with out-of-hours centres. Where possible, the MDU advises the doctor who made the notes should also transcribe them, as soon as possible.
A GP on a home visit saw a middle-aged man who had intermittent claudication. The GP noted gross evidence of peripheral vascular disease and made a note including that specific observation on a slip of paper. He did not have the notes with him as the request for a home visit had come unexpectedly during the lunch hour and the doctor made the visit on his way back to the surgery.
As was the practice custom, the GP gave the paper record of the consultation to one of his receptionists for transcribing. The receptionist noticed the initials PVD and also saw a statement that the patient was impotent. She transcribed the note as the patient having 'venereal disease' and the transcription was not checked.
The mistake only came to light (the following week fortunately) because the GP attended a lecture by an MDU medicolegal adviser on the dangers of acronyms, and remembered his note. The practice instituted a rigorous checking system of any transcriptions and a clarifying note was put against the PVD entry.
The case mentioned is fictitious, but based on cases from the MDU's files. Doctors with specific concerns are advised to contact their defence organisation for advice.
Nicholas Norwell is an MDU medicolegal adviser