Roman Hasil and the Whanganui DHB - Health and Disability ...
Roman Hasil and the Whanganui DHB - Health and Disability ...
Roman Hasil and the Whanganui DHB - Health and Disability ...
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<strong>Health</strong> <strong>and</strong> <strong>Disability</strong> Commissioner<br />
— Record-keeping<br />
A fundamental element of good medical practice is good record-keeping. Cole’s Medical<br />
Practice in New Zeal<strong>and</strong> states: 37<br />
“[Record-keeping] is a tool for management, for communicating with o<strong>the</strong>r<br />
doctors <strong>and</strong> health professionals, <strong>and</strong> has become <strong>the</strong> primary tool for continuity<br />
of care in many practices as well as in hospitals. To fulfil <strong>the</strong>se tasks, <strong>the</strong> record<br />
must be comprehensive <strong>and</strong> accurate.”<br />
It is a doctor’s responsibility when making a record of a consultation with a patient<br />
(particularly a h<strong>and</strong>written record) to do so in accordance with professional <strong>and</strong> ethical<br />
st<strong>and</strong>ards — which include writing legibly, recording <strong>the</strong> date <strong>and</strong> time, <strong>and</strong> signing <strong>the</strong><br />
notes legibly.<br />
Dr <strong>Hasil</strong> did not complete <strong>the</strong> “Gynaecological record sheet” for his consultation with<br />
Patient A on 1 March 2006, but briefly recorded <strong>the</strong> consultation as follows:<br />
“G 4 P 3 NVD [normal vaginal delivery]<br />
unwanted fertility<br />
gynae examination NAD [no abnormality detected]<br />
PAP taken<br />
for sterilisation”.<br />
His letter to Patient A’s general practitioner reiterated his findings <strong>and</strong> plan.<br />
My advisor stated that Dr <strong>Hasil</strong>’s record of <strong>the</strong> initial outpatient assessment was<br />
inadequate, with minimal clinical history <strong>and</strong> no details of examination. Although a<br />
general consent form was signed at <strong>the</strong> assessment visit, <strong>the</strong>re is no evidence on <strong>the</strong> form<br />
related to specific complications, including failure of sterilisation. Dr B subsequently<br />
recorded that a discussion of <strong>the</strong> risks of surgery <strong>and</strong> <strong>the</strong> giving of an information<br />
pamphlet were “not documented but done” by Dr <strong>Hasil</strong>.<br />
Dr Brown advised that Dr <strong>Hasil</strong>’s record-keeping was inadequate <strong>and</strong> <strong>the</strong> st<strong>and</strong>ard<br />
clinical record sheet for gynaecology patients was not utilised properly. I accept that Dr<br />
<strong>Hasil</strong> did provide some information regarding risks of sterilisation to Patient A.<br />
However, he failed to document his discussion.<br />
I note Dr <strong>Hasil</strong>’s submission that in an inadequately resourced department, it is likely that<br />
st<strong>and</strong>ards for record-keeping will be <strong>the</strong> first failing for any health practitioner. However,<br />
I am satisfied that <strong>the</strong> adequacy of his record-keeping has been considered in context. In<br />
my view Dr <strong>Hasil</strong> should have made more detailed note of his consultation with Patient<br />
A. I consider that his st<strong>and</strong>ard of record-keeping was inadequate <strong>and</strong> that he breached<br />
Right 4(2) of <strong>the</strong> Code.<br />
37 Ian St George (ed), Cole’s Medical Practice in New Zeal<strong>and</strong> (Medical Council of New Zeal<strong>and</strong>, 2004)<br />
p 68.<br />
68 February 2008