Retrospective Medical Note Entries and Doctors
Retrospective Medical Note Entries Made By Doctors
When a doctor needs to correct a previously made medical note entry, or write a medical note entry to explain something that has happened in the past, they must make it clear that they are making a retrospective entry at the time of writing. This is to avoid the suggestion that there has been a false entry or a ‘cover up’.
Each year a number of doctors are accused of falsifying medical note entries, or of adding a letter to a file, to cover up an act or omission. Allegations of misconduct might follow in such circumstances. To avoid this, great care needs to be taken to set out what should have been included previously.
Where a computer entry of written entry has been made which needs to be corrected or additional information, it should be stated the date on which the entry is made and the reason for it. See the following working example of a fictitious doctor needing to make a retrospective entry:
Retrospective Entry made by Dr J D Foxtritt on 14/9/24
On 10/9/24 I made an entry in the medical records. This retrospective entry is to record [additional] important information that [I omitted to include at the time] or [I need to correct], and which it now is important to include…. (then make the entry, signing it and dating it, with designation and sufficient details for someone later on to identify who made the entry).
All correspondence that has been generated prior to the retrospective entry will also need to be reviewed, to see whether a new letter needs to be generated. The old letter should remain on file, but one might write on the original letter to ensure that there is no confusion:
This letter has further information in a later letter: See the letter of retrospective correction dated X/X/XX…
And the new letter should state something like:
Retrospective Correction/Erratum of Previous Letter Dated Y/Y/Y
This letter is retrospectively written to make a correction / erratum of a previous letter which did not include the following important information ……
Or a letter which needed to add further information:
Retrospectively Written Letter to Add Further Information to Letter Dated D/D/DD
This is a retrospective letter made by x on date F/F/FF to clarify that on G/G/GG date…
Any newly generated letter must make it clear that it is an update or a replacement of the previous letter. It should state that it is a retrospective letter to correct or add additional information to the original letter, which will need to be cross-referenced with sufficient detail to ensure the recipient is clear about the purpose of the new letter.
A failure to do the above or take a similar bespoke approach could lead to criticism. Local policies may be available to guide doctors on the specific approach to be adopted in an institution. Take local advice on the local best practice or protocol. In some instances, a senior doctor or administrator may need to be informed and counter-sign the retrospective entry or document. Some organisations may have template letters or formal policies that must be adopted. It is important to take advice, and to not work in isolation when a retrospective entry needs to be made, so that there can be no suggestion of impropriety.
In McGuinness v Nursing and Midwifery Council [2017] EWHC 325 (Admin) an appeal was dismissed. The findings against a nurse were upheld. The NMC had found that:
“9. Your action(s) as set out in charge 8.2 were dishonest in that you sought to disguise the fact that you had already administered the medication in 8.1.
“The panel has found charge 8.1 proved in full, and has also found that the words “needs to be given” were added at a later stage to the daily evaluation sheet.
“The panel noted that at this time Ms McGuinness was aware that her actions were subject to greater scrutiny than would normally be the case for a band 5 nurse simply because she appeared to be making a large number of basic errors. The panel considered whether as a registered nurse she would consider it dishonest to alter medical records retrospectively, without recording a retrospective alteration, and to put information in those records which she knew not to be accurate. The panel concluded that as a registered nurse she would know such actions were dishonest and that her actions were motivated by an attempt to mislead others and to protect herself.”
(28 February 2017)
If you are a doctor seeking legal advice in relation to a retrospective entry concern, call Doctors Defence Service on 0800 10 88 739