There will be circumstances when amendments, if well intended, are acceptable but generally speaking notes should becontemporaneous.

Dr M was a final year GP trainee.  Patient A made an urgent appointment because of shortness of breath, she had a phobiaof doctors and had not visited one for approximately 40 years.  The clinic did not classify the appointment as urgent, the appointment was possible because they kept some slots available.  Dr M conducted an examination at around 9am,concluded she had a chest infection and discharged her with antibiotics. Patient A’s partner returned home from work at4:25 pm, saw she was pale, arranged another GP examination and she was taken to hospital at 8pm.  Patient A died laterin the early hours of the morning, it was attributed to acute respiratory distress syndrome secondary to acute viralpneumonitis.

A number of allegations were made about Dr M.  It was alleged that she had not properly taken readings using theoximeter because Patient A’s hands were cold and shaking.  As a consequence, it was alleged there were errors regardingher oxygen saturation levels that should have been picked up and were not.  There was an alleged discrepancy regardingblood pressure measurements and further that Dr M had amended her notes after learning of the death and having had aheated conversation with Patient A’s partner in the days following the death.  Patient A’s partner had taken a screen shot ofthe records immediately after the death and noted they were different to the ones submitted to the coroner at the inquest.

It was correct that there were issues with the Oximeter, it was flashing up different numbers, however they were all in the90s and the expert evidence was that Dr M was not in error relying on the readings in the manner she had.  She wasmoderately criticised for not recording those numbers in her notes but commended for using an oximeter which was notthen widespread.  It must be noted these events occurred before Covid when respiratory distress syndrome was somethingGPs would see less than a handful of times in their working lives.

In respect of the notes it was alleged that Dr M had made the amendments dishonestly.  However Dr M was aware that her alterations would be tracked, she later understood she should have made a new note, she had received little formal training on the EMIS records system.  She had acted partly defensively, the amendments were to clarify and add detail, they were not false or inaccurate.  The Tribunal properly took account of her low level of experience, training and naivety about the process, it also acknowledged the evidence which was that the notes were of good quality even before the amendments.

GMP Guidance provides (at paragraph 19 ) that – “documents you make (including clinical records) to formally record your work must be clear, accurate … You should make records at the same time as the events you are recording or as soon as possible afterwards”.   GMP does not give guidance on amending notes, the experts referred to a “perceived wisdom” which is really only acquired through experience.

On the facts, happily there was no finding of impairment.  Dr M acknowledged that she had made a mistake and had undertaken relevant training.  Were the facts different the consequences could have been more serious.  For example, were she to have deleted her old notes, added details that were inaccurate or false, it is likely her fitness to practise would be found to be impaired and a sanction imposed.  More experienced doctors should know to make notes contemporaneously and it would be more difficult to explain later amendments.

Please note that the comments in this case review are generic, if you have any practise concerns please contact us directly for specific advice on your matter.