A recent claim made against an MDDUS member highlights the importance of recording 'negative' as well as 'positive' results of diagnostic tests.
Our member, Dr L, was a GP working in an out-of-hours clinic in a general hospital. A patient attended Dr L with pains in his chest and forearms. The doctor stated that he took the patient's blood pressure but, as the reading was normal, did not record the result or the fact that he had carried out the test.
The patient later died of a coronary thrombosis and his family disputed that a blood pressure test had been carried out (among other complaints about his care). We were unable to substantiate our member's claim as there was no supporting record. We obtained expert opinion on this case and the report contained the following paragraph:
"It is becoming less and less acceptable to record only positive responses, partly for the obvious medicolegal reason but also because of the fragmentation of medical care with out of hours shift working: it's helpful to any doctor seeing the patient later to have negative as well as positive findings recorded."
Good and accurate records are essential in responding to and defending against complaints and claims of negligence. Often accurate, legible and complete notes and other records are the only defence. No record can be considered complete without full documentation of diagnostic tests ordered and the results. Memory is unreliable and a doctor's 'word' will rarely stand up as a defence in court.
ACTION: record all diagnostic results - positive and negative.