'The standard of written medical records'

Dr Kathryn Leask, medico-legal adviser

The old mantra 'if it wasn't written down, it didn't happen' isn't quite true when it comes to medical records and recording consultations and other interactions with patients, but having good documentation is key to defending and justifying your actions.

The GMC states that documents must be 'clear, accurate and legible' and should include relevant clinical findings, what decisions and actions have been agreed and what information was given to the patient.

Recording in the notes can be time consuming in an already pressured environment, but it is definitely worth the extra time. If a patient questions a doctor's actions, detailed clinical records are invaluable in responding to concerns. You can refer to your usual practice and recollection, but this won't be as persuasive as good notes.

It is important, however, to not only record what you've found and said to the patient, but also any relevant negative findings and any other important information; for example, the fact that you offered a chaperone but the patient declined.

You can guarantee that it'll be the patient for whom your notes weren't up to standard who will complain, with the potential for those notes to be scrutinised by various third parties, including the GMC.

'Amending or altering the medical records'

Dr Ellen O'Dell, medico-legal adviser

If you want to make additions or alterations to a medical record, make sure that you enter your name, the date and time of your amendment, the additional details and sign the entry.

It is essential there is an identifiable audit trail of all changes made so that no-one can accuse you of tampering with the records and attempting to pass off the amended entry as contemporaneous. Such actions have led to local disciplinary proceedings as well as GMC investigations.

'Ensuring systems are in place for follow-up'

Dr Sharmala Moodley, deputy head of underwriting

Delayed or missed diagnosis is the number one cause of claims the MDU settles on behalf of GPs. Problems with tracking test results or acting on information from other parties can feature in these cases, so it's important to have systems in place to review or act on results and correspondence to ensure patients are managed promptly.

There should be clear procedures to guide staff and ensure consistency. All clinicians and support staff should know of the follow-up systems in place and whose responsibility it is to deal with each step. A safeguard should be introduced so that if a result or response is not received within a specified time, the requesting clinician (or another in their absence) is informed.

Risk management: top issues and advice

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Risk management: top issues and advice