Empowering patients – helping your doctor to help you
Clearly, good records will help your clinician to help you better – whether that be a doctor, nurse, midwife or dentist. Patient should be empowered and encouraged to take an active role in making sure their records are complete and accurate.
Below is a case study and some advice on how you can help your doctor to keep full and accurate records of any medical treatment you receive.
CBX v North West Anglia NHS Foundation Trust
The strength of medical record evidence when compared to a patient’s witness evidence, was discussed in Court at the trial in the above named case.
This case involved a mother who was pregnant with twins. It was the mother’s case that she had asked for delivery of her babies by Caesarean Section when she had a meeting with one of the treating doctors in clinic, but that this request was refused. She had expressed how unhappy she was with the refusal and was distressed and upset at this meeting. However, nothing was put in her medical records about this or about her wish for a Caesarean Section.
Her babies were subsequently born without a Caesarean Section, and one baby suffered an injury during birth.
A compensation claim was thereafter started on behalf of the injured baby, alleging that delivery by way of a Caesarean Section should have been carried out as the mother had asked – in which case the baby would not have been injured.
The Defendant Hospital admitted that with a Caesarean Section, the baby would not have been injured, but it denied that the mother had asked for a Caesarean Section.
The Judge at the trial favoured the clinical records over the witness evidence, despite the fact that the mother’s partner, sisters and mother also gave evidence to say the mother had requested a Caesarean Section.
The Judge found that there was insufficient evidence to suggest that the mother had asked for a Caesarean Section, and the Judge therefore found in favour of the Defendant, meaning the baby would not receive compensation from the Hospital for the injuries suffered.
This case highlights the importance of a complete and accurate medical record. Our recommendations set out below provide several ways in which you can improve the quality and accuracy of your medical records.
The claim of Mrs Jacobs
What a patient clearly remembers about what happened in relation to medical treatment may not be accepted by the Court, if the record made by the nurse at the time does not support this – even if the record kept is minimal and only a few words long.
This was the finding of the Court in the case of Mrs Jacobs, who recently lost her claim against the Kings College Hospital NHS Trust.
Mrs Jacobs had a lump in her groin and had surgery to remove it. However, she clearly remembers that after the operation, the lump in her groin was the same as before. She also clearly remembers that she complained about this at the clinic appointment after the operation, but the clinic nurse reassured her and said things would settle down.
At the clinic appointment, the nurse made a very brief entry in the notes that the wound was healing and that there were no problems. The lump did not settle down and Mrs Jacobs subsequently needed further surgery to remove the lump. This time, after the second operation, the lump had gone.
Mrs Jacobs complained that the first operation had been done negligently as it had not removed the lump. As a result, she was forced to undergo a second operation under general anaesthetic, with further pain, more scarring and the need to recover.
The Hospital denied it had failed to remove the lump at the first operation and said that the lump must have been gone at the first clinic appointment, otherwise the nurse would have written in the notes that the lump was still there. The hospital said that the second operation was needed because a new lump had formed in the very same place, which was not the result of negligent care.
The Judge at the trial of the claim, found that if Mrs Jacobs’ memory was correct, then there was negligent surgery, but if the clinic note was correct, then there was no negligence.
Because both parties completely disagreed about what happened at the clinic appointment, the Judge decided to go with the evidence of the Hospital and accept what was recorded in the medical notes, he thus did not accept what Mrs Jacobs told him at the trial. Mrs Jacobs lost her claim.
Visit our hospital negligence claims page for more information.
Patients are at a disadvantage
Patients are at a disadvantage when things apparently go wrong. Patients do not control what is recorded in their records about them and don’t normally see what is recorded so they also don’t have an opportunity to correct any mistakes made in the records. Patients are therefore dependent on clinicians to record correctly and fully what is being said and done.
The problems with incomplete/incorrect records
The above cases are examples of the problems a patient may face as a result of incomplete or incorrect entries made in their medical records, when they want to make a claim for negligent care.
Other problems may occur, including:
- If the records do not fully set out what the patient’s problems are, the next doctor who sees the patient does not have all the information needed to make the correct diagnosis and give the correct treatment.
- If the records are incorrect/incomplete about the patient’s problems, a patient may be referred to the wrong specialist, resulting in delays in treatment.
- If the records are incorrect/incomplete, a patient who is deteriorating may not be seen quickly enough and treatment to improve the symptoms may not be provided in time.
Doctors and nurses are imperfect, like all of us. They therefore need help in creating complete and correct records, and to achieve the best medical outcomes for their patients.
WHAT YOU CAN DO TO HELP YOUR DOCTOR HELP YOU
To help improve the quality of your records, you could consider doing any (or all) of the following:
Ask your doctor to copy you in, on each and every letter they send about your care to others. You will need to mention this to the receptionist when you book in at the surgery or hospital at your next visit and ask them to update your details to make sure all letters are copied to you.
If you keep all these letters on file, you will have a note of what is going on. You can use this for your next appointment and you can make sure your doctor has understood the issues.
If you have any concerns or want to discuss specific problems with your GP or Hospital Doctor, write an email to them with your symptoms and questions before your next appointment. You can obtain the email address from them or their secretaries by phoning up and asking for it, before your appointment. This way, your clinician has a chance to look at your records before your appointment and see if there is anything of relevance that might help them in diagnosing and treating your problem. It is also less likely that you will forget to mention any of your symptoms or to address all of your questions at the upcoming appointment.
If you keep a copy of all your medical correspondence then it will assist you in your next appointments.
If you are concerned about the way a wound looks, about a skin mark, or about the colour of your leg for instance, take a picture of it (and of the other side for comparison) so you can show your clinician. You can help to demonstrate the size of your wound by putting a 20p coin next to it in the photograph.
If you send the photo to your clinician (by email, together with a list of your symptoms and concerns), they may be able to bring forward your appointment if necessary. Most people can take pictures with their mobile phones and again if you keep a copy of it on your file it may help with future appointments. You can also take a photograph on the days following the first one, so you can show your clinician any changes (for better or worse) that may occur.
More and more people video record parts of their lives, be it car journeys, holidays or social events. Recording a discussion with your doctor or nurse can be really helpful in allowing you to replay what was said and done afterwards, and make sure you have understood everything.
This can be in relation to an appointment in a hospital clinic, at your surgery, in the A&E department or while an in-patient in hospital.
We recommend you tell your clinician that you are recording the discussion and that you keep a copy of the recording afterwards, for your file.