Altering notes Flashcards
You are the IMT1 working on the gastroenterology ward.
One of your registrars has asked you to amend an entry in the notes from yesterday in which you documented the patient’s consent for a ward-based procedure.
You have been asked to add in writing that “the risks of bleeding, infection and damage to local structures were explained to the patient who fully understands this”. At the time, you did not think these risks were fully discussed with the patient.
to seek more information = he might have already had a conversation about the risk which i did not hear
or
It is possible a patient has come to harm or raised a complaint
patient safety is my priority - a patient with mental capacity without informed consent is seen as ASSAULT
It is possible that this registrar is also unsafe to practice and is trying to cover their back after an unsafe procedure
would refuse to alter the notes on behalf of the registrar since this would not constitute good medical practice and could be misleading
suggesting they write a new entry in the notes stating exactly what was discussed at the time.
Escalating your concerns to a senior such as the consultant responsible for the care of the patient or your clinical supervisor is also likely to be necessary in the event that the registrar was seeking to amend an entry in the notes. This is particularly important if the patient has come to harm.
Finally, you may need to reflect on what would be a very challenging situation personally.
How would you define informed consent?
it is a process in which the risks and benefits of a medical procedure or treatment are explained to a patient, to allow them to agree to this course of action whilst understanding the reasoning and any alternative options available.
Written consent should be taken by whom?
Written consent should be taken by the person performing the procedure. It is not appropriate for junior doctors to take consent for procedures that they are not qualified to carry out
What would you do about written consent if a patient is deemed not to have capacity and a procedure is needed in their best interests?
they are likely to regain capacity and if so whether the procedure or investigation can wait until this is the case.
It may be necessary to involve a fellow allied health care professional to assess capacity, for example a Speech and Language Therapist if the patient has difficulty with communication.
Finally, any valid Advance Directives to refuse certain treatments must be respected
If the patient does not have capacity and there is no advance directive to refuse treatment, then the procedure can still go ahead in a patient’s best interests. Most hospital trusts have a different written consent process (for example a ‘consent form 4’) to address this situation. The procedure would instead need to be discussed with the patient’s lasting power of attorney (LPA) if they have one, or another next of kin if not.
