A GP from your practice forgets to write up his notes from a home visit to an elderly patient. The patient subsequently requests a copy of her notes from the practice and the GP admits his mistake. What should you do?
The GP should write up a note in the patient’s records for the visit now, but clearly sign and date the entry to indicate when it was written and include a brief explanation of why it was entered late.
The practice should ensure the GP apologises to the patient and that it has a robust system in place to record home visits promptly. This is particularly important for any doctor who goes on a home visit directly before taking time off, or for locum GPs who may not be scheduled to return to the practice in the near future.
Dr Gail Gilmartin is a senior medical adviser at the Medical and Dental Defence Union of Scotland
Practice dilemma: Forgotten home visit