Documenting your consultations

Record keeping is an essential part of nursing practice – not only to ensure continuity of care but also to ensure that a claim against you can be defended

After completing an MA in Medical Ethics and Law, I decided I wanted to make use of it beyond my own practice and joined a firm of nurse experts who are called upon to advise on clinical negligence claims. Too often a claim can be validated based not on what actually happened, but on what was written down in the records. Documentation can make the difference between a claim going forward and being dismissed – not just in court but before it even gets to court.

In this article we discuss the importance of robust documentation practices and how they can inform clinical and medicolegal decisions. By the end of this article, you should be able to:

• Recognise why careful documentation is important
• Implement a structured approach to documenting consultations
• Reflect on the use of appropriate vocabulary and terminology
• Assess how medicolegal principles might inform documentation practice

WHY CAREFUL DOCUMENTATION IS IMPORTANT

Documenting what happened in a consultation is an essential part of nursing and medical care. The record of the consultation should include the history, examination findings, recommendations, decisions and follow up planned for the individual.¹ This will ensure that care is structured and streamlined, and that the clinician concerned – and any other clinician who may become involved in the ongoing care of that patient – has a clear picture of what has gone before and what was planned for the future. Increasingly, patients are accessing their own records and so it is also important that that what is written is clear, concise and comprehensible to anyone who reads them.

The Royal College of Nursing has developed a guide on record keeping which describes the key considerations when writing records and which can be downloaded from their website.² These include the importance of writing records contemporaneously and not waiting until later when some of the details of the consultation may have been forgotten. Handwritten records should be signed, with the time and date but this will happen automatically with digital records. However, it is still essential that information technology (IT) users are aware of how to use this technology in a way which maximises security and confidentiality.

IMPLEMENTING A STRUCTURED APPROACH

It can be challenging trying to work out what to record, why it is important and how information should be documented. Using a structured approach to each consultation can help. There are many different models which advise on how to structure a consultation and these may be a starting point to remind the clinician about what needs to be covered in the consultation and therefore, by definition, what should be documented.

Acute, ‘same day’ consultations

In the article on cardiovascular examination in this issue, the ‘CPD for Simple Folk’ model for history-taking is described:

C – current presentation

P – past medical history

D – drug history

F – family history

S – social history

F – feelings i.e., the patient’s ideas, concerns and expectations regarding the consultation

Recording each element of this process will offer a firm basis for explaining how a potential diagnosis has been made. The clinician will then need to go on to note the examination carried out, the findings from that examination and the possible diagnosis. This will then inform the basis for requesting tests or a referral and planning ongoing management.

Planned care

Consultations for planned care such as smear tests, vaccinations or wound management all require careful documentation. Consent can be verbal, written or implied, but there should still be evidence that it has been sought and it is always a good idea to document that consent has been obtained for any procedure.³ Consent is not valid unless it is informed. i.e., the individual involved has been advised as to why the care being offered is recommended, what other options are available, and what the risks and benefits of the intervention are.

Third party consultations

These may be needed when consulting with a child or an adult with impaired cognitive abilities. Children and adults with impaired capacity may need an adult with them to help them understand the options available to them and to support them with their decision-making or, in some cases, making those decisions for them.⁴ In any case where decisions are made for a non-competent adult the concept of it being in the patient’s best interests is key. This principle should be followed by the responsible adult and the clinician alike.

Children automatically have capacity to consent to medical care at the age of 16, although the right to refuse treatment is not automatic until they reach the age of 18.⁴ Of course, children younger than 16 can consent to treatment if they are Gillick competent (Fraser competent for issues pertaining to contraception).⁵ This has been demonstrated recently when the government reminded clinicians that competent children can override a parent’s refusal for vaccinations such as the coronavirus jab, if the child wants it. This is not new – competent children can always make their own decisions and have a right to confidentiality, too.

Competency depends on the individual being able to understand and analyse the information they are given in order to make a decision and they should also be able to communicate that decision appropriately.⁶ In people with cognitive impairment, such as dementia, their ability to consent may fluctuate and they should be assessed for each proposed intervention. These legal requirements make the importance of recording consent clear.

TERMINOLOGY AND ABBREVIATIONS

As you might expect, abbreviations and jargon should, by and large, be avoided. In a legal situation, a lack of clarity in the documentation may be used to cast doubt on the meaning of what is written there. A colleague recently described how he would write his initials ‘AF’ on an ECG after he had read it until he realised how that could be misconstrued. Abbreviations such as PND can mean postnatal depression, post-nasal drip or paroxysmal nocturnal dyspnoea. The context of the consultation may help to clarify the intended meaning but in consultation with a patient who has a cough and breathlessness, would the phrase ‘reports symptoms suggestive of PND’ indicate exactly what the patient was reporting? It is essential that the use of abbreviations is restricted to those in common use and where there is unlikely to be any confusion as to their meaning. For example, when recording an individual’s observations, the use of the abbreviation BP is unlikely to be misinterpreted.

Another common mistake is to be vague when recording findings. It is better to record what has been observed and measured, rather than using words such as ‘appeared to be’, unless there really is no way of being certain – for example, ‘the patient was agitated and appeared to be experiencing auditory hallucinations’. Conversely, the records of an individual who ‘appears unwell’ need objective evidence of the ways in which they were unwell – e.g., they were pale, flushed, cyanotic, unsteady, pyrexial with a temperature of 38.6 degrees, nauseous.

Far less common these days is the use of pejorative terminology whether disguised as abbreviations e.g., NF…’normal for (insert name of a town)’ or written in full: when summarising records in the past I have seen the phrase ‘TRIVIA’ written in capitals across the patient notes. These days this would reflect very poorly on the clinician involved and could be used to question the professionalism of the healthcare professional and the holism of the care being offered. Sometimes it is not the content of the documentation that will be used to support a negligence claim but the quality and tone.

LINKING ACTIONS TO EVIDENCE

One way in which documentation can be used to support good practice is by linking the evidence to action. For example, when treating diabetes, there is the option to follow NICE guidance, the ADA/EASD consensus document or local guidelines.^7,8 The recommendations may differ from guideline to guideline and so linking the action you have taken to recommendations made in specific guidelines can help to support your actions if they were called into question. This also helps to identify the rationale for what occurred in any consultation, which can be important in the legal context.

If someone is accused of negligence, there has to be a duty of care which was breached and that breach has to have led to harm which was predictable.⁹ If the action (or omission) which led to the harm can be defended, the negligence claim will not be able to proceed. Common defences may include the Bolam principle and the Bolitho ruling.^10,11 Both of these look to compare what happened in the consultation compared with what should have happened. Bolam will be used to identify what is common practice, whereas Bolitho is more focused on what would be reasonable and logical practice.

Either way, there will be a comparison of what did happen with what should have happened and the ‘should have’ will involve looking at common, logical and/or reasonable practice. If your notes link what you did to the evidence for what you did, there is a greater likelihood that a negligence claim will be rejected. As an example, NICE has different cut-off points for managing hypertension to those in other guidelines but writing that ‘the patient’s blood pressure is within the target range as per NICE 2019’ suggests that you know what the guidelines say and are working within them.¹² The same goes for asthma and COPD, where NICE, BTS/SIGN, GINA and GOLD all have different approaches to diagnosis and management.^13–16 Align what you do to a specific guideline and, as long as it fits the criteria for reasonable and logical practice, it will be harder to prove negligence.

Montgomery

Another important consideration when documenting consultations is the Montgomery principle.¹⁷ This came about as a result of the Montgomery case where the claimant complained that she had been given inadequate information on which to base a decision about treatment risks and benefits. The defence was that if she had had this information, she could have been unduly alarmed and have chosen an option that put her at greater risk. The case went all the way to the Supreme Court where it was decided that when discussing the risks and benefits of an intervention, the patient should be told what they wanted to know, and not what the clinician deemed it necessary for them to know. The ruling specifically said that it was not the frequency of the risk that was important (e.g. how common a side effect is) but the severity of even rare side effects that people might want to know about and that it was paternalistic for clinicians to screen the information provided to people before they made decisions about their care. Importantly, the Montgomery ruling is retrospective, meaning it applies to consultations that occurred before the ruling, as well as those that happened afterwards. This is something worth considering when discussing risks with patients and documenting those discussions.

Offering people the opportunity to ask about risks that matter to them is key to observing the Montgomery principle and documenting that the discussion occurred in line with Montgomery again indicates that you are aware of it and have observed it. The Montgomery principle underlines the importance of shared decision making and dialogue between patient and clinician and the records need to indicate that this has been integral to the consultation.

CONCLUSION

Careful documentation helps the clinician providing care to take a structured approach to history taking, diagnosis and care planning. This also helps clinicians who may become involved in the patient’s care later on to understand the process that has led to the diagnosis and planned management. Aligning documentation to evidence and guidelines can indicate why actions were taken, especially when different guidelines recommend varying approaches. Being aware of medicolegal principles including Bolam, Bolitho and Montgomery can also impact positively on the quality of documentation.

REFERENCES

1. Mathioudakis A, Rousalova I, Gagnat AA, et al. How to keep good clinical records. Breathe 2016;12(4):369–373. https://doi.org/10.1183/20734735.018016

2. RCN. Record keeping; 2017 https://www.rcn.org.uk/professional-development/publications/pub-006051

3. NHS. Consent to treatment; 2019 https://www.nhs.uk/conditions/consent-to-treatment/

4. Department for Constitutional Affairs. Mental Capacity Act 2005; 2017 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/921428/Mental-capacity-act-code-of-practice.pdf

5. Care Quality Commission. GP Mythbuster 8: Gillick competency and Fraser guidelines; 2021 https://www.cqc.org.uk/guidance-providers/gps/gp-mythbuster-8-gillick-competency-fraser-guidelines

6. Zhong R, Sisti DA, Karlawish JH. A pragmatist's guide to the assessment of decision-making capacity. Br J Psychiat 2019;214(4):183–185. https://doi.org/10.1192/bjp.2019.17

7. NICE NG28. Type 2 diabetes in adults: management; 2015 (updated 2020) https://www.nice.org.uk/guidance/ng28

8. Buse JB, Wexler DJ, Tsapas A, et al. 2019 update to: Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2020;63:221–228 https://doi.org/10.1007/s00125-019-05039-w

9. Connelly A, Serpell M. Clinical negligence. Anaesth Intensive Care Med 2020;21(10):524–527 https://doi.org/10.1016/j.mpaic.2020.07.006

10. Bolam v Friern Hospital Management Committee [1957] 2 All ER 118-28.

11. Bolitho v City and Hackney Health Authority [1997] 3 WLR 1151-61.

12. NICE NG136. Hypertension in adults: diagnosis and management; 2019 https://www.nice.org.uk/guidance/ng136

13. NICE NG115. Chronic obstructive pulmonary disease in over 16s: diagnosis and management; 2019 https://www.nice.org.uk/guidance/ng115

14. BTS/SIGN. BTS/SIGN British Guideline on the Management of Asthma; 2019 https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/

15. GINA. GINA Report, Global Strategy for Asthma Management and Prevention; 2021 https://ginasthma.org/gina-reports/

16. GOLD. Global Strategy for Prevention, Diagnosis and Management of COPD; 2021 https://goldcopd.org/2021-gold-reports/

17. Royal College of Obstetricians and Gynaecologists. The impact of the Montgomery ruling; 2016 https://www.rcog.org.uk/globalassets/documents/members/membership-news/og-magazine/december-2016/montgomery.pdf