Guidance ‘wrong’ on amending clinical notes

Tags: BMA GP GPs LMCs London

19 Aug 2008

When the Londonwide Local Medical Committees issued advice to its members on correcting clinical notes it seemed a straightforward matter. Don’t do it – add a correction with a date and explanation.

The only problem is that, according to Paul Cundy, a London GP and chair of the Joint GPs IT Committee, this advice is wrong.

Now the “professional voice of London general practice” may have to back track.

The original advice, issued in August under the title “free text facility on computer notes” said that the Londonwide LMCs had been made aware of a small number of cases where GPs’ notes had been amended using the edit facility.

“Any attempt to amend a contemporary clinical note, even with the best intentions, unless the date of amendment and the reason for it are both explicit, is liable to misinterpretation and criticism and may have clinical governance implications,” it says.

It could even result in a GP being referred under fitness to practice procedures, it adds.

“Our advice is that clinical notes should never be altered, even if this is to correct an obvious error, but that a correction should be added, with the date of the correction, and any relevant explanation.”

But Dr Paul Cundy, a London GP and chair of the Joint GPs IT Committee, the combined IT group of the Royal College of General Practitioners and BMA, said this was wrong and runs counter to the professional guidance endorsed by the Department of Health, BMA and RCGP.

He said: “This is confusing and not strictly true. When you edit an entry you create a new duplicate and the original is retained”

He added: “This is not a new problem and has been covered in good practice guidelines. The Londonwide LMCs need to get it down and get it right.”

Sue Broom, director of communications for LondonwideLMCs Ltd, said she would look into the issue and correct the advice as necessary.

Daloni Carlisle

Reader's Comments

Dangers of not editing record

angus.goudie@GP-A89021.nhs.uk

19 Aug 08 19:08

A computerised record is so different from a paper one where the advice would be appropriate to merely append a text comment. The computer record is not accessed in dimension like the Lloyd George folder but is multidimensional and much of its coded content is recognised by various methods of searching and filtering, some by the end user, some by automatic audits that produce alerts, reminders and include him or her in registers of e.g. IHD. Any text addition will not prevent the patient appearing in an IHD register, and will lead to end users treating the patient on the basis of the pre-edited erroneous content. Of course editing must be clear so that users can see that there has been a change, and on what grounds. The fine detail, however, for medicolegal purposes as has been said should all be there in the way the system produces its audit trail.

2 years 9 months and counting

20 Aug 08 13:08

Angus points out the distinction between a paper and an electronic record. I would add a second - that between a true shared electronic record and a (de facto) single user system.

In medicine one is typically dealing with opinion. That opinion may be 'coded' rather than free text does not alter this. Also the value of the data declines (unpredictably) with passage of time.

So someone thinks there is an error in a shared record....

Can an erroneous entry simply be left to 'time out'?

Can only the individual who created that record 'deactivate' an entry? Can [only] their locum/team/profession/institution deactivate it?

Is there a professional pecking order for overriding entries? Does the report / audit / billing system / decision support system prefer a consultant's coding to the junior doctor's? Does the diabetic nurse's entry today supercede the (conflicting) entry by the physiotherapist last week?

What was the rhetorical question again? "If {insert large financial institution of choice here} system can do it why can't healthcare?"