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Good Record Keeping and Clinical Notes
Good Record Keeping and Clinical Notes

Clinical notes and clinical records. How to avoid complaints.

Locum PA Team avatar
Written by Locum PA Team
Updated over a week ago

One thing that trips up a lot of locums is record keeping. When working in a normal GP practice working with the same team on a regular basis the team get to really know you as a clinician and trust you and your judgment. This often means that we in our salaried get away with cutting corners when it comes to documentation. We have all seen partners one liner consultations.

I have always been adamant that a clinician should focus on the patient rather than the screen in front of them(I personally hate defensive medicine, and think it's egocentric the opposite of what our jobs should be). I have had bad experiences seeing defensive, young GPs who haven't glanced at me more that 2 seconds in a consult. So much so that I stopped speaking until they glanced over. Its a horrible experience for patients as a standard.

Finding a middle ground of defensive note taking vs rapport and eye contact with a patient is a skill that takes time and practice. However as a Locum things are a bit different. You're working in an environment where you don't have the time to build up years of trust with the team. They are consciously or not making a judgement on you from the moment you arrive at practice and being honest these are not always rationally based. Often the impressions made are on the only information they have at hand and this if not always factual.

Its important as a Locum to remember impressions count and documentation needs to go the extra mile when working with a new team or a new patient demographic.

Those few extra moments writing that little extra detail can make the difference when a complaint raises its ugly head. This little bit of extra attention and care to detail can be the difference between being removed from the practice in the event of a complaint or enjoying the benefits of an ongoing locum position.

A recent example of this would be instead of writing "No red flags" its better to list the pertinent negatives. It takes a few minutes more but it shows to the team if ever questioned you actually know what the red flags are.

Often with complaints they can come out of nowhere. What I like to call "The sniper complaints", you don't see them coming! These are often where a patient will drag you into a complaint even if you're not the primary issue. Often this happens when multiple clinicians have seen a patient for the same issue or when the system as a whole has let them down. The patient will aim their sights at whoever they can to get heard.

As a locum please take care to protect yourselves and always be mindful you're in a new place and a new profession, people are naturally going to be more interested in your activities.

Further info and Advice.

Please see our complaints article.

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