Surgeon’s documentation found to be below standard

Adequate records are not simply for the benefit of the treating practitioner, they are important to enable others to understand the care provided and ensure continuity of patient care. Documentation should provide an accurate, complete and contemporaneous record of what took place and should never be altered or tailored to provide a more favourable account.

Dr T was a specialist obstetrician and gynaecologist, practising primarily in gynaecological oncology. The Medical Board alleged Dr T’s clinical management of six patients was unsatisfactory and that his documentation was inadequate, misleading and potentially falsified.  This summary focuses on the documentation aspects of the case.

Medical records

The board argued Dr T’s consultation and surgery notes were inadequate in several cases in that they were too brief and did not satisfy the standard reasonably expected.

Based on the requirements of the Code of Conduct, the tribunal found that surgery and clinical notes:

• need to be legible and intelligible
• must capture the essence of the surgical procedure or clinical encounter accurately so that another practitioner, who was not involved, could quickly grasp the essence of the procedure or encounter and thereby facilitate continuity of patient care.

Operation reports

Given their importance in the immediate post-operative management of a patient, operation reports must also be contemporaneous and complete and clearly and accurately document:

• the relevant surgical and pathological findings
• the surgical procedures performed
• technical details that enabled the procedure to be completed
• events that occurred or were encountered during the operation that may influence the outcome of the procedure or patient outcome.

They should also include post-operative orders.

If relied on for billing, operation reports must also contain sufficient information about the procedures performed to justify billing and each of the Medicare Benefits Schedule items claimed.

It is appropriate to use clinical photographs and video to complement notes, and these should be accompanied by adequate written detail to explain, locate and orient the images and what they portray.

Ultimately in several cases the experts opined, and the tribunal accepted, that Dr T’s operation notes were overly brief and inadequate for various reasons.

Some records did not accurately or properly describe the procedure. Others did not include sufficient detail about the indications for surgery, technique, findings, complications or blood loss. Some did not make it clear specifically what had been removed, or did not describe the extent and location of residual disease.

The tribunal concluded in these cases Dr T’s documentation was below standard, although not substantially so.

In one case, the tribunal found Dr T’s consultation notes did not record the patient’s concerns about the surgery outcomes or ongoing symptoms, nor the information and advice Dr T had given her.

The board was critical of Dr T’s documentation in the other cases. However, the tribunal found these complaints were not made out. There was no need to record absence of findings (for example active bleeding) unless these were clinically relevant or necessary to justify specific surgical decisions. The mere fact that a record was brief did not make it inadequate.

Documenting informed consent 

The tribunal found that the standard for documenting informed consent requires that a record be made to confirm details of:

• the nature of the procedure
• why it is proposed – its objective having regard to the patient’s condition
• the expected benefits from the procedure and the degree of uncertainty about the outcome
• the risks associated with the procedure, including those specific to the procedure itself, general risks associated with surgery (including risks referable to the patient's health or condition), and any common outcomes and side effects
• any costs associated with the proposed procedure, including out of pocket costs to the patient.

The record should document the patient's consent to the procedure in light of all of that information.

This information could be contained in more than one document.  If any part of the discussion has been delegated to a more junior doctor, the senior doctor is required to ensure that a written record has been made of the informed consent that has been given.

Professional integrity - altering medical records

In one case, the evidence included two versions of Dr T’s consultation notes made electronically – one from the active system and one from the backup copy. The backup copy version of the note included a sentence, indicating that the patient was symptomatic with signs of early bowel obstruction.

The board alleged Dr T had manufactured evidence by altering the consultation note after the fact to add the sentence, in support of his decision to recommend surgery over other conservative options.

However the technical evidence indicated, and the tribunal accepted, that the relevant sentence could only have been added on the same day as the record was created. After that, the record would be ‘locked’ and any amendment would show as an addendum. 

There were also two different versions of letters to other health care providers about the content of the relevant consultation, one of which contained the relevant sentence and one of which did not. There was evidence before the tribunal that sought to understand when and how the two versions were generated, but ultimately the tribunal could not draw any conclusions to explain how the discrepancies in the record came about.  

In the end, the tribunal was not satisfied the board had established that Dr T had fraudulently altered the record at a later date to justify his decision to operate.

Professional integrity - inaccurate records

In the same case, the board alleged Dr T’s surgery records were false, that Dr T had knowingly included inaccurate information about the extent of tumour he had removed and that his account was contradicted by later scans.

However, the tribunal accepted the evidence of the expert witnesses who opined that the scans did show the removal of disease masses and that it was very difficult to tell from a scan exactly how much disease remained. The experts opined that this assessment can only be made by surgeon and even this assessment is inherently unreliable.

The tribunal concluded that while the record was not entirely accurate, in that Dr T had not debulked all sites, it was not persuaded the record was knowingly false. It represented Dr T’s genuine understanding of what was achieved, that is, he had removed the tumours necessary to achieve the operation’s palliative purpose and that his actions in not removing further tumour had been clinically appropriate in the circumstances and given the patient’s wishes to avoid a stoma.

The tribunal found Dr T’s clinical documentation was below standard in relation to three patients but not substantially so.

Dr T was reprimanded and ordered to contribute $20,000 to costs.

Medical record keeping 

Keeping appropriate documentation of surgical procedures, patient consultations and consent processes is not a mere administrative requirement, nor are records simply for the benefit of the treating practitioner. They are necessary to allow others to understand the care provided and ensure continuity of patient care.

Records need to be legible and intelligible. They need to capture the substance of a consultation, treatment or procedure so that another practitioner, who was not involved, can quickly grasp that substance and provide appropriate care and management of the patient.

In the event of an adverse event or unhappy patient, records will often come under scrutiny, and it is important they provide an accurate, complete and contemporaneous record.

Never attempt to delete or rewrite records at a later date. If you need to correct an error in a handwritten record, strike through the error and note the changes in a way so as not to obliterate the error or delete any existing information. For electronic records, you should not delete or alter any parts of the existing record. Instead, add an addendum note referring to the information being corrected. Clearly identify that you have made the addendum, including the date it was made and the reason for entering in the additional information.   

Never attempt to portray a consultation, procedure or patient incident in a better light by altering your records. This will raise concerns about your professional integrity and may be seen as risking patient safety and public confidence.

Avant factsheet – Consent: the essentials

Avant factsheet – Substitute decision-makers

Avant factsheet – Medical records: the essentials

Avant article – Here’s the right way to correct medical records

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