Doctors could face a potential negligence claim by simply ticking the wrong box on patient assessment forms, says UK-wide medical defence organisation MDDUS.
MDDUS has seen an increase in calls from members facing patient complaints due to errors filling out forms – with the completion of HGV licence applications proving particularly problematic due to recent changes in the format.
While analysing closed cases against GPs involving communication errors, MDDUS risk adviser Alan Frame found that ten per cent 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,” said Frame.
He added: “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.”
Some of these errors have occurred when filling out HGV licence renewals which can have serious implications for patients.
Frame said: “One error resulted in the licence being rescinded and a subsequent claim by the patient for loss of earnings as they were unable to work until the licence had been renewed.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.”
Following recent changes to the HGV licence forms, 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.
MDDUS medical adviser Dr Mary Peddie is reminding doctors of the importance of completing documents carefully when providing information about or for their patient.
“Filling out these forms may be a time-consuming task of low priority for a busy GP,” said Dr Peddie.
“After all, a doctor’s main focus is on providing the best possible care for their patient. “However, 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.”
GMC guidance Good Medical Practice states: “You must make sure that any documents you write or sign are not false or misleading. You must take reasonable steps to check the information is correct.”