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Medical documentation is an integral part of a doctor’s day-to-day clinical practice. The Medical Council of Hong Kong (Medical Council) has recently sentenced a medical practitioner to a suspended removal order, subject to certain training requirements, for failing to maintain proper and adequate medical records for his patients.
Background
The employer of five patients lodged a complaint with the Medical Council alleging that the doctor failed to maintain adequate medical records in respect of their consultations with him. The doctor, upon request, provided copies of his clinical notes which were later passed to the Medical Council’s expert witness for advice.
Guidelines
Medical practitioners in Hong Kong are subject to the Code of Professional Conduct for the Guidance of Registered Medical Practitioners (Revised in October 2022) issued by the Medical Council (the Code). Non-compliance with the provisions therein may result in disciplinary actions.
Section 1 of the Code deals with medical records and confidentiality. Medical record is defined to be “formal documentation maintained by a doctor on his patients’ history, physical findings, investigations, treatment and clinical progress”. It documents the basis for the clinical management of a patient and is necessary for continuity of care. Section 1.1.3 imposes a duty on all medical practitioners to “maintain systematic, true, adequate, clear, and contemporaneous medical records”.
Decisions
The Medical Council found the doctor to have failed to keep proper and/or adequate medical records in respect of the five patients. His conduct was said to have fallen below the standard expected of registered medical practitioners in Hong Kong. The doctor was therefore found guilty of professional misconduct in respect of the disciplinary charges. In convicting the doctor, the Medical Council expressed agreement with the opinions of the expert witness, who commented upon the following issues.
Missing particulars
The expert witness opined that the entries on the clinical notes were all very simple and almost only contained the patients’ pain status and their unreadiness to return to work. The doctor did not include the location and cause of injury, areas of joints involvement, their range of movement, degree and severity of pain, loss of function or any nerve involvement in the history and examination. The psychological status of the patient, which is normally required for patients having a prolonged period of sick leave, was not documented.
Lack of medical history
The expert witness found that there was no information as to the patients’ medical history which might shed light on the underlying cause(s) of the accidents and known side effects of drug taking in the clinical notes provided by the doctor.
Repeated entries
Repeated phrases were found in the clinical notes when the doctor issued sick leave certificates on multiple occasions without any physical examination being documented. One of the patients visited the doctor, on a weekly basis during the course of less than nine months (a total of 44 occasions). On each visit the patient was issued with a sick leave certificate for seven days with the same entry of “accidental low back and neck injury”. The expert witness also observed that a physical examination was not undertaken at any of the follow-up appointments or subsequent consultations, which is the most important part of the consultation in eliciting clinical signs and determining the severity and progress of injury.
Sentencing
The Medical Council commented that it has to ensure that the doctor will not commit the same or similar misconduct in the future given his repeated failures to keep proper and/or adequate medical records in respect of multiple patients. The Medical Council did, however, take into account a number of mitigating factors, including the doctor’s clear disciplinary record and his admission. The doctor was sentenced to a one-month removal from the General Register, to be suspended for 12 months, subject to the completion of courses relating to medical record keeping and medical ethics, and satisfactory peer audit by a Practice Monitor appointed by the Medical Council.
Observations
The Medical Council continues to stay at the forefront of maintaining professional standards in the medical profession. Inadequate medical records will result in disciplinary action by the Medical Council. There is an ongoing trend where more serious sentences will ensue upon the Medical Council’s finding of guilt against medical practitioners for their failure to maintain adequate and proper medical records. The trend has once again been manifested in the present decision.
Maintaining proper medical documentation remains an important duty imposed upon medical practitioners. Medical records which set out doctors’ clinical findings, test results and the patient’s conditions serve crucial functions in a patients’ treatment. Similarly, such records may potentially assist in a medical practitioner’s defence in a subsequent legal claim or complaint. The adequacy of medical records is measured depending on the circumstances of individual cases. The Medical Council will often engage expert witnesses to determine issues of adequacy of documentation in the circumstances. For example, whether physical examination should have been carried out in light of the complaints made and any findings should have been appropriately documented. Therefore, with the importance of medical documentation in mind, medical practitioners should exercise their professional judgment to ensure sufficient documentation is made in their clinical practice.
Healthcare
Hong Kong