 Good notes can protect your family, too
The importance of good clinical notes and records is a recurring theme in cases dealt with by the CMPA. Not only do good notes help ensure that patients receive proper care, they also help in demonstrating the quality of care provided by a physician. In addition, clinical notes are crucial when the estate of a deceased physician must defend that physician's care in a legal action. In one case, the basis of the plaintiff's allegation was that the physician had not provided sufficient information to obtain an informed consent prior to undertaking a procedure. The procedure resulted in a complication, which prompted the patient to commence a legal action against the physician. The CMPA assisted the physician. During his discussions with legal counsel, it was obvious the physician had a clear recollection of the information he had provided to the patient, although he had not documented any of it in his clinical records. The physician died before his evidence could be taken under oath. There was thus no admissible evidence to refute the plaintiff's claim of lack of informed consent, and it was not possible to obtain support for the physician's care in this case. The physician's family was placed in the unenviable position of having to accept that his actions could not be defended and a settlement had to be made. Compensation was paid by the CMPA on behalf of the physician's estate. How sad it was for the family to witness this ending to the physician's dedicated professional career. Careful notes might mean neither you nor your family need face this situation.
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DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.
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