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Filling out patient assessment forms correctly

GPs could face a potential negligence claim by simply ticking the wrong box on patient assessment forms. MDDUS medical adviser Dr Mary Peddie outlines the risks involved

GPs must take care to fill out patient forms correctly (Picture: iStock)
GPs must take care to fill out patient forms correctly (Picture: iStock)

There seems to be no limit to the number of forms, certificates and official documents that require the approval and signature of a doctor. For healthcare professionals who already have many demands placed on their time, it could be easy to become complacent when presented with ever increasing piles of paperwork.

MDDUS regularly receives calls from clinicians on issues relating to signing, for example, firearms certificate applications, forms relating to a patient’s capacity or fitness to travel, letters relating to patients making a court appearance and other legal documents.

Carrying out an assessment

If you have agreed to undertake an assessment, this should be done in a timely manner, taking care to ensure that all relevant information is provided accurately. Documents should be read carefully before signing to ensure they are truthful and honest.

It is vital that clinicians check what they are being asked to sign before endorsing it. Anyone who fails to read the small print could face serious consequences if it is found they have signed-off a document that later turns out to contain inaccurate or misleading information.

One case dealt with by MDDUS involved a doctor who provided a report to an insurance company that was deemed misleading and he was referred to the GMC. While the case was eventually resolved in his favour, the doctor endured considerable anxiety while his professional conduct was called into question.

Errors on assessment forms

While analysing closed cases against GPs involving communication errors, MDDUS found that 10% of these claims involved a doctor error on an assessment report form.

We have had cases resulting in claims simply because a doctor ticked the wrong box or missed out important information on a form. There is always a risk of human error – especially when resources are stretched. Our experience tells us that even routine tasks in a busy practice can have consequences for doctors.

Lapses in concentration and poor attention to detail can have a serious effect on quality and safety. The chance of a simple error occurring increases when undertaking tasks that may be repetitive and routine in nature.

How to reduce the risks

Asking a colleague to check a completed form or report checked before sending it out is one possible risk reduction measure to consider.

Doctors should also consider where and when they carry out such work to minimise the risk of errors occurring. Is it immediately after a consultation where available time is limited? Is it during a lunch break when, really, you should be having a break? Is it at the end of a busy day when your concentration levels are exhausted? Is it after you have just signed off 50 repeat prescription requests? Or are you working in a main office surrounded by noise, distractions or interruptions? 

Changes to HGV licence applications

MDDUS cases reveal that completion of HGV licence applications has proved particularly problematic due to recent changes in the format. This can have serious implications for patients.

One error resulted in the licence being rescinded and a subsequent claim by the patient for loss of earnings as they were unable to work until the licence had been renewed. In extreme cases, patients can also lose their jobs if they are prevented from driving while the matter is resolved.

Doctors should read the notes contained in the INF4D leaflet before completing the Medical Examination Report (D4 form). It includes the following information:

'The medical examination report (D4) now includes a vision assessment that must be filled in by a doctor or optician/optometrist. Some doctors will be able to fill in both the vision and medical assessment sections of the report. If your doctor is unable to fully answer all the questions on the vision assessment you must have it filled in by an optician or optometrist.'

Section B has other information that the doctor should be familiar with, such as what sections to complete and specific details to be obtained from the patient.

Steps to minimise problems
  • Have a colleague check any forms or reports that you complete.
  • Make sure you are able to concentrate properly when you complete forms.
  • Ensure you are aware of any key changes to forms that you regularly complete, for example recent changes to the HGV licence D4 form.

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