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MDOs advise GPs to be extra careful if forced to revert to paper records

Medical defence organisations have urged GPs to take extra care if they have to revert to paper records during clinical consultations.

The advice comes as swathes of practices reported being affected by the NHS cyber attack, which spread a malware programme that encrypted computer files and left GPs unable to access patients’ medical history.

MDDUS said doctors were ‘advised to revert to time-honoured methods of noting a detailed history by making hand-written records, ensuring they are accurate, legible, contemporaneous, timed and dated’, and – once systems were restored – ‘the hand-written note should be recorded within the patient’s electronic records’.

Joint head of the medical division Dr John Holden said: ‘Our members can be reassured that by following some simple steps to ensure patient safety at this time, they will have our support and access to indemnity in the unlikely event of a litigation claim or other complaint arising.

‘If a doctor doesn’t have access to medical records, then we would advise them to act in the patient’s best interests and apply a traditional approach to the situation, tailored to the individual circumstances on a case-by-case basis.’

He added that ‘given the absence of past medical history, doctors should take extra care to double check any relevant medical information with their patients and document these discussions’ and ‘prescribe for the minimum period necessary unless they are able to sufficiently verify the drug history’.

GPs are also urged to contact labs by telephone if results from clinical investigations are not available online.

Medical Protection medico-legal adviser Dr Helen Hartley said: ‘Doctors will of course be keen to continue seeing their patients and providing the best possible care despite the disruption, and MPS members can be reassured that their indemnity arrangements are not affected by the current IT issues…

‘It is important that doctors seeing patients without the benefit of electronic medical records exercise heightened vigilance – taking time to establish a patient’s history and any allergies for example.’

She added that ‘once electronic records become available, early consideration should be given to patients who have complex medical problems, those with outstanding investigation results, and patients who have seen a doctor recently where reviewing the notes may prompt a different response or treatment pathway’.

‘Any doctors who have concerns about their indemnity, or require medicolegal advice, can contact their medical defence organisation.’