Mai i te Kaitirotiro Tūpāpaku | Recent Coroner’s report
The importance of refraining from amending clinical notes after being notified of a patient’s death.A recent Coroner’s report has highlighted the importance of refraining from amending clinical notes after being notified of a patient’s death.
Maintaining accurate and timely clinical notes is an important part of a doctor’s clinical practice. Council published guidelines, titled ‘Managing Patient Records’ in December 2020, which outline the responsibility for clinicians managing all aspects of recording and maintaining clinical notes including guidance on handling patients’ records.
When reporting a critical incident, it is important that doctors do not alter existing clinical notes. Rather, doctors must add an addendum or additional (augmentative) note to identify different, corrective, and outstanding information. Even where incorrect information may have been recorded in the initial record, a subsequent clinical note must carefully outline or describe the corrected information and justification for its recording.
Following a critical incident, clinicians may want to record as much information at the time or shortly after the critical event. This may assist with subsequent report writing necessity (e.g. coroners’ reports). This is where additional clinical record writing is encouraged rather than changing pre-existing information. Where retrospective insight can produce a different formulation of the situation, this must be recorded in the additional note and not by altering former notes.
