Risk: Paperwork pitfalls

PRACTICES receive requests for patient reports from a variety of organisations, including employers, insurance companies and government agencies – and as such they are part of the daily routine. But a recent analysis of GP cases conducted by MDDUS has identified the extent to which failures in the processing of patient reports can lead to complaints and sometimes claims for negligence.

Here I will explore some of the things that can go wrong when managing requests across the full multidisciplinary process from request to completion.

Request received

When a request for a patient report arrives at the practice it is important that patient consent is attached. Under the Access to Medical Reports Act (1988), companies must ask a patient’s permission to request a medical report from their doctor. Patients may also choose to see reports before a practice submits it to the company.

Important points to check at this step are:

• Has the patient consent form been signed recently (less than six months prior to the date of request)? The older the consent is, the less valid it becomes (unless of course the request for a report comes as the result of a patient’s death and relates to a life insurance policy). If consent is not recent, the patient should be contacted to confirm that they are happy for the practice to comply with the request.
• Does the information requested in the report go beyond the remit of the statement the patient has signed? For example, the information requested may appear to be more extensive than the patient is likely to have anticipated based on the consent given, or the doctor may find information in the medical record that the patient might not realise could be detrimental if disclosed. If in doubt, check with the patient before complying with the request.

It is essential that you only provide information that the patient has consented to but it is also important to ensure that any additional checks do not cause unnecessary delay in complying with the request. If a doctor chooses to withhold information which does not fall within the scope of patient consent, ensure that the person(s) requesting the report are informed of this.

Some types of report allow for patient review prior to submission, such as those covered by the Access to Medical Reports Act (e.g. insurance reports). It is important to be aware that there could be a conflict between the interests of the patient, the requirements of a third party and the obligations of a doctor to provide accurate information. Some types of report do not require patient consent, specifically where the doctor is legally obliged to produce the information, but it is good practice to inform the patient, where possible.

Work-flowing the request

Careful consideration should be given to practice policies around the allocation of a doctor to complete a patient report. Whilst it is important not to overload any particular doctor with such requests, systems which simply use an allocation rota could cause difficulties. An important consideration here is whether any of the doctors know the patient.

If a patient is known to a doctor this could assist in completing the form more efficiently of the patient’s attitudes around sensitive information, the disclosure of which falls within the scope of the consent provided. In some cases, the patient may have wished the doctor to restrict the extent of information provided.

It is also important to note any special need to expedite the request. This may affect who can complete the report as a doctor may be on leave, or may not have current capacity to comply within the required timescale.

Audit trail and monitoring

In order to avoid complaints and claims associated with delays in complying with requests, it is essential to maintain an administrative log of each patient report. Useful information to record might include:

• date of request and related patient
• company or person(s) requesting the report
• nature of the report requested and whether the practice can/should comply
• whether appropriate consent is included
• whether the patient is allowed/has requested to review the report before submission
• a record of the agreed fee for completion and who is liable to pay this (advice on fees is available from the BMA)the urgency of the report and required completion date
• which doctor has been allocated the report
• agreement from the allocated doctor (it may be that – after discussion with the patient – completion of the report may not be in their best interests or the doctor may not feel equipped to provide the required information)
• expected date of completion.

Practice managers should have knowledge of each doctor’s workload and capacity in relation to completion of patient reports. It can be helpful to agree an informal standard for timescales. This can help the administrative team deal with any enquiries on completion dates and ensure that consistent failures to meet timescales are addressed – or indeed that the timescales for completion should be reviewed. It may be helpful to diarise a reminder for the doctor, with their prior agreement, so that the agreed deadline for completion is not passed.

Accuracy of information

Accurate completion of requests for patient reports and forms is essential. Several recent claims for negligence have arisen due to a loss of earnings or a delay in pay-outs on insurance claims – many relating to doctors making errors on insurance reports and DVLA forms and reports. The latter are likely to attract claims where the patient requires a current /appropriate driving licence to carry out their job; a large proportion of these are linked to HGV reports and solely relate to a doctor ticking the wrong box on a form.

When completing forms, doctors should ensure that they read each statement carefully. Some questions can move from negative to positive wordings which may be confusing, particularly if the doctor is under time pressure.

Some patient systems are able to produce editable template information for inclusion in patient reports. This can be helpful; however, the quality of information extracted is directly proportionate to the quality and consistency of input information. Where information is automatically extracted, it is important to review this from two angles. Firstly, what has been missed and, secondly, what has been included that is excessive, irrelevant or outside the scope of the request.

A further area of risk is overreliance on a previously completed patient report. Whilst it may be tempting to use existing information as a starting point – or indeed the core section of a new report – this strategy can lead to the perpetuation of a previously missed error.

Doctors should stick to facts rather than personal opinion when completing reports and if the requested information is outside their sphere of knowledge or competence, the doctor should state this where relevant, or even advise that another party may be better qualified to supply the information required. Doctors withholding any patient information in a report should include a statement to this effect: for example information which may be harmful to the patient or a third party.

Completing the process

Any expected delay in the completion of a report should be communicated proactively to the person(s) requesting it. This can help to manage expectations and prevent complaints.

Patient requests to review a report before it is sent should be facilitated where appropriate. A patient who does not agree with information included within a report has the right to ask for it to be amended – or for a statement of their objections to be included with the report. The patient also has the right to ask for the report not to be released and this should be communicated promptly to the company or person(s) requesting the report.

And it goes without saying that when sending out patient reports ensure the mode of transfer is secure – be it paper or digital.

Liz Price is a senior risk adviser at MDDUS