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Is it ever OK to recreate medical records?

 

Keeping accurate medical records is the responsibility of every doctor for the continuing good care of patients. Sometimes when a doctor looks at their records after the event, for example when a complaint is made, they may feel that their previously recorded notes are inaccurate or incomplete, and may be tempted to correct them, or even rewrite them.

A recently reported court case involving a General Practitioner (GP), highlights the importance of accurate, contemporaneous notes and why rewriting medical records, especially with dishonest intentions, is unethical.

Doctor presents recreated notes as contemporaneous

The case involved a GP with a special interest in skin cancer who had completed a Primary Certificate in Skin Cancer Medicine. Complaints were made to AHPRA at various times relating to four patients. Two involved complaints of boundary violations and two regarded complaints of a failure to perform an adequate skin check and failure to make adequate notes.

At various times during the complaints process and with the intention of misleading AHPRA’s investigation into the complaints, the GP deleted the original, brief notes he had made during his consultation with three of the patients, and replaced them with a more comprehensive version. The doctor sent the new version of the notes to AHPRA, claiming them to be contemporaneous.

Falsifying records constitutes professional misconduct

The doctor claimed that the recreated notes accurately recorded what had occurred, however the Tribunal determined that this was not the case.

In reaching its decision, the Tribunal said the doctor’s reliance on the recreated medical notes to assist their case reflected poorly on their character. The doctor’s insistence that the new notes were an accurate depiction of what had occurred during the consultation suggested to the Tribunal the doctor had little insight into the serious nature of their misconduct.

“The circumstances of the boundary violation, considered separately, would not warrant de-registration nor would the failures to properly carry out skin checks and make adequate notes. These are serious, but they could reasonably be dealt with by imposing conditions as to further training and mentoring,” the Tribunal said.

It was the doctor’s deliberate attempts to deceive that led the Tribunal to cancel the doctor’s registration. The Tribunal found the doctor made four attempts to deceive the AHPRA in order to influence the conduct of the investigations, and that these were inconsistent with the doctor being a fit and proper person to hold registration in the profession.

The Tribunal said, “It is of the utmost importance that practitioners conduct themselves in an ethical manner, especially in matters involving investigations into a practitioner’s conduct, which are necessary for the protection of the public.”

The Tribunal described the doctor’s professional misconduct as serious and unethical, and said there was no evidence to suggest the doctor suffered genuine remorse. The Tribunal decided the doctor had behaved in a way that constituted professional misconduct on four occasions and unsatisfactory professional performance on two occasions and the public would be best protected by cancelling their registration. The doctor was de-registered for three years.

Key lessons

  • Honesty and integrity are key attributes of being a professional. The Medical Board’s Code of Conduct notes that patients expect that doctors will display qualities such as integrity, truthfulness, dependability and compassion.
  • It is your professional responsibility to keep accurate up-to-date and legible notes that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners. Records should be made at the time of events, or as soon as possible afterwards.
  • In this case, the matter for concern is the deliberate attempts to deceive. It is paramount that doctors conduct themselves in an ethical manner, including in matters involving investigations into professional conduct.

This article was originally published by Avant Mutual. You can access the original here.

Is it OK to attend your patients’ funerals?

 

She’s a long-time patient, and over the years, your professional relationship has developed a certain personal dimension. You treat her in her decline, refer her to palliative care and she passes away in a hospice. Should you attend her funeral? Or does this cross a professional line? It’s a delicate question that hasn’t been much examined in the medical literature.

In a recent opinion piece, a Melbourne-based anaesthetist looked back at her management of a patient with pancreatic cancer, who she helped “navigate the tortuous terrain of mortal illness”. Dr Katrina Barber found herself a first-hand witness to the “raw emotion that spills over with the coming of death”.

“I wondered whether it would be appropriate to attend the funeral of that patient. Even after the worst had happened, I didn’t have the answer.”

Although Dr Barber ultimately did go to the funeral, she points out that “the right course of action for one doctor may not be the correct course for another.”

She notes that while the presence of a doctor may offer comfort to the patient’s family, it could also “stir up problems rather than bring solace”. It could invite anger or recriminations from the family who may blame the clinician for the loss of the patient’s life. There may also be wider-ranging implications concerning patient confidentiality.

Given that this is a dilemma likely to be faced by most doctors, surprisingly little research has been done on doctors attending patient funerals. But one of the only recent studies on the subject is Australian. Researchers from the University of Adelaide carried out an anonymous survey of 437 doctors and found that most had attended at least one patient funeral. GPs were the most likely to have attended a funeral (71%), while surgeons (52%) and ICU specialists (22%) were the least likely.

Female doctors were more likely to have attended a patient funeral, and they were also more likely to do so out of grief for the patient’s death rather than a sense of obligation. Women were also more open to crying at a funeral and discussing going to funerals with their colleagues. Young male doctors were the least likely to attend.

Study co-author Associate Professor Greg Crawford, who works in palliative medicine, said the benefits of attending a patient funeral may be twofold: “It’s a practice that may help physicians deal with their emotions after a patient dies, and in turn it can also be of comfort for the patient’s family,” he said.

But he said there were differing views in medicine about its acceptability, with some doctors feeling it to be unprofessional and other feeling that their colleagues might disapprove of them.

“The medical community should ask itself whether funeral attendance needs to – and can – be addressed more openly, whether death and dying should be discussed more candidly among health professionals, and what effects these discussions may have on job satisfaction and on the mental health of medical practitioners,” the study authors wrote.

Is it ever OK to prescribe for friends and family?

 

If you’ve been practising for any length of time, you’ve undoubtedly faced the dilemma of a friend or family member asking you whether you could write a prescription for them. Often it’s a repeat script for a treatment they’re already on, when it’s inconvenient for them to go to their GP. You might think that’s fair game – but is it really wise and safe to go ahead and write that script?

It’s a complex issue. First up, there’s the question of whether there could be any legal ramifications in prescribing for people with whom you have a close, non-patient relationship. The trouble is that legislation on this varies from state to state. Broadly, it is legal to prescribe for family members everywhere except in South Australia, where S8 medications can only be prescribed in a “verifiable emergency”.

Prescribing for you own use is more contentious. All states and territories ban self-prescription of S8 drugs, although NSW, NT, Queensland and South Australia will allow it under certain emergency conditions. All states except Victoria allow self-prescription of S4 drugs, but with varying levels of restrictions.

But even if it’s legal to prescribe for friends and family, there are other questions to consider. Many professional indemnity insurance policies specifically exclude claims arising from elective medical treatment provided to a doctor’s immediate family, which could leave you significantly out of pocket should anything go wrong.

And if things do go wrong, there’s not just insurance coverage to think of. The practice is not recommended by the Medical Board of Australia and there have been cases where it has led to disciplinary action.

A recent case involved a NSW doctor who had been in private practice for 30 years, with no previous disciplinary record or conditions on his registration.

He was found to have provided wrongful and inappropriate prescriptions to his adult children and spouse, including S4D medications. Conduct issues were confined to his prescribing habits for his family and did not involve the day-to-day treatment of his patients.

In handing down its decision of professional misconduct, the tribunal referred to the Medical Council of NSW guidelines for self-treatment and treating family members, which supplements the recommendations of the Medical Board’s Good Medical Practice.

Here’s what the latter document has to say about prescribing for family, friends or oneself:

“Whenever possible, avoid providing medical care to anyone with whom you have a close personal relationship. In most cases, providing care to close friends, those you work with and family members is inappropriate because of the lack of objectivity, possible discontinuity of care, and risks to the doctor and patient. In some cases, providing care to those close to you is unavoidable. Whenever this is the case, good medical practice requires recognition and careful management of these issues.”

The upshot of this and other advice from the regulatory bodies is that:

  • It is not advisable to treat family members, friends, or yourself;
  • In an emergency situation, provide only the immediate treatment needed before handing the person over to an independent doctor;
  • You can collaborate with a family member’s treating doctor, as long as you’re not the primary doctor;
  • If you do treat a family member, document the treatment and provide it to the primary doctor;
  • Make sure you have your own GP.

It’s not always easy to resist emotionally-based pressures, especially when they come from friends or loved ones. But it’s precisely these subjective emotions that don’t mix well with the appropriate and objective care of a patient. A good idea is to prepare a sympathetic explanation beforehand as to why you can’t prescribe for them. It might run along the lines of: “I’d love to help out, but I’m afraid that kind of thing is frowned upon by the Medical Board. Let me see if I can get hold of a colleague for you.”

And remember that each time you do prescribe for someone, you are entering into a doctor-patient relationship with that person, even if she or he is a family member.

Sources: Avant, MDA National