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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.