Ensuring good record-keeping and timely referrals

Dr James Thorpe, Senior Medical Educator and Medico-legal Consultant, outlines how medical records that demonstrate
satisfactory assessment and decision-making can help protect doctors against future claims and complaints

Medical Protection provides expert advice and support to GP members on medico-legal matters arising from their professional practice. This can include providing assistance with claims for compensation, complaints to the Medical Council and providing advice and legal representation for our members when they are required to attend a coroner’s inquest.

We are aware just how stressful being involved in a medico-legal case can be so we recently examined Medical Protection cases involving GPs in Ireland over a three-year period, in order to identify common themes. The findings are published in our report, Learning from cases – insight into the claims landscape for general practitioners in Ireland.

Medical records

Poor medical record keeping was an issue identified in one in five of the GP claims reviewed. Good medical records are a vital component of providing high quality, safe patient care and they are often viewed as a reflection of the standard of care that was provided. The quality of medical record-keeping in general practice is highly variable.

The challenges of record-keeping will not be surprising to practicing GPs, especially during the ongoing Covid-19 pandemic when new ways of working such as the increased use of remote consultations have been introduced rapidly.
There are numerous reasons why we don’t always keep good records, but a common reason provided by doctors is that they have insufficient time. Whilst this can certainly be a challenge, good medical records are vital as they provide an insight into the clinical judgment being exercised at the time. Adequate medical records that enable you, or somebody else, to reconstruct the essential parts of each patient contact should also be sufficient should they be required for medico-legal purposes, for example if the patient pursues a clinical negligence claim. Remember that accurate and clear documentation, which often may need to be relied upon years after the event, is the cornerstone of any medico-legal defence.

Adopting a structured approach to record-keeping will help to ensure that documentation is maintained at a high standard and is as accurate as possible. Good records should include:

• Context
• Consent- History and assessment – including examinations and observations
• Options based on diagnosis
• Safety- netting
• Follow up

Medical records demonstrating that clinical decision-making has been based on a thorough assessment of the patient can help protect you in the event of future claims and complaints.

Referrals

A quarter of the claims and pre-claims (intimations from a claimant of a possible claim for compensation) that Medical Protection assisted with between 2017-2020 involved a delay in the diagnosis of cancer. Of those cases, nearly half involved female cancers – breast, cervical and endometrial – with breast cancer being the most frequent cancer involved in the claims reviewed.

The remaining three quarters of claims and pre-claims involved a wide range of clinical conditions. Of these cases, over half involved allegations of a delayed diagnosis or a failure to refer a patient to secondary care appropriately. A number of claims involved a delayed or missed diagnosis of cauda equina syndrome (CES), appendicitis, peripheral vascular disease or cardiac chest pain. In relation to CES, a frequent allegation against GPs was their failure to refer to take further action in the presence of ‘red flag’ symptoms’.

Delays in referrals were identified as common systems or contributory factors in many of these cases. Referral is a key part of the GP role and it is a complex area where decision-making involves the balancing of several competing concerns and sources of information. Often the first presentation to the GP provides a referral opportunity to allow early diagnosis of the underlying cancer.

Contributory factors relating to referrals included:

• Referral delayed and not followed up
• Referral not sent as urgent
• An urgent referral not followed up
• Missed and lost referrals
• Failure to refer to a specialist at an earlier point in time

It is interesting to note that our findings with regards to contributory factors concur with previous patient safety research, particularly in demonstrating that Practice systems issues were at the heart of many cases. It is therefore vital to ensure GP practices have a system that allows them to view or access a list of overdue referrals that may require review or further action to ensure that a referral has been received and acted upon. A record should be kept of any steps that are taken to follow up on overdue referrals. It would also be beneficial for GPs to keep their own log of patients referred, so that they can ensure that the referral has been sent and the patient received care within an appropriate period of time. Checking that a referral has been acted upon is a prudent safety net measure.

Case example

A 52-year-old male patient with a family history of prostate cancer was advised by the GP to have a prostate-specific antigen (PSA) test. The result showed an elevated PSA level which was reviewed by the GP, who intended to make a referral to the hospital. Unfortunately, the patient was not informed of the abnormal test result and did not receive a hospital appointment.

The patient subsequently attended the GP on several further occasions with unrelated issues. The patient did not request his earlier blood test results and the GP did not re-visit the abnormal result. Four years later, the patient attended complaining of frequent micturition and when his PSA test was repeated, the result was again found to be elevated. Rectal examination revealed an enlarged prostate gland and he was referred immediately to the rapid assess prostate clinic. Unfortunately, he was diagnosed with prostate cancer and required a radical prostatectomy.
The GP recalled that he intended to refer the patient to the urology clinic following the first abnormal PSA result. However, he could not remember whether he made the referral, and nothing was documented in the records. The records were generally lacking in detail.

Key learning points

• Ensure robust and reliable practice systems for the review, action and follow up of all test results.
• Ensure robust practice systems to log refferals which enable the practice to identify missed referrals.
• Maintain complete and contemporaneous record keeping of all patient interactions and consultations.

Our research reinforces the message that accurate and clear documentation, which often may need to be relied upon years after the event, is a key component of medico-legal defence. The implementation of patient safety improvement interventions with regards to the follow up of test results and referrals are also vital in order to reduce harm to patients, and avoid complaints and medicolegal action.

Read the ‘Learning from cases – insight into the claims landscape for general practitioners in Ireland’ report at
medicalprotection.org/ireland/gpclaims