Health Professionals Advised to Take Their Own Notes with Challenging Patients
This matter before the Health Professions Appeal and Review Board (the “Board”) provides guidance on when a health professional should take their own notes rather than rely on the notes of a trainee or colleague.
Complaint
A patient of a neurologist and a physiatrist made a complaint to the College of Physicians and Surgeons of Ontario (the “College”), as he was concerned with the medical care and conduct of the physicians during a consultation. The patient had been involved in a workplace accident and suffered an electric shock injury. He suffered from various symptoms and was seen by numerous physicians, physiotherapists, and psychologists through the Workplace Safety and Insurance Board.
In 2015 he was examined by the neurologist and physiatrist at the same time. As this occurred at a teaching clinic, the patient was initially assessed by the neurologist’s clinical fellow in neurology, to whom the patient explained his issues. The report for the consultation was dictated by the clinical fellow and signed by both the neurologist and the physiatrist. The patient did not agree with the resulting recommendation that he should receive active physiotherapy. The patient had already undergone active physiotherapy. He advised the physiatrist that it had uniformly negative effects. The patient alleged that the physiatrist did not believe him.
The patient complained to the College that the physiatrist should have performed the complete examination himself, rather than rely on the examination by the clinical fellow, among other issues.
The Investigations, Complaints and Reports Committee (“ICRC”) of the College was concerned that the physiatrist did not document in the report that he found the encounter with the patient to be difficult and that there was significant disagreement between the parties regarding diagnosis and treatment of his condition. The ICRC stated its expectation that, in circumstances where the physician-patient encounter was unusual or challenging in some respect, the physician must ensure that they personally document this in the record, rather than simply relying on the note prepared by a trainee. Aside from this stated expectation, the ICRC chose to take no further action.
The patient requested a review of the ICRC’s decision. The Board found that the ICRC’s investigation was adequate and its decision was reasonable. The ICRC was satisfied that the physiatrist did repeat certain aspects of the examination after the clinical fellow had performed the initial examination, although this was not specifically documented in the report. The information in the report, however, provided support for the ICRC’s conclusion, and the Board confirmed the ICRC’s decision to state its expectation with respect to notetaking.
Takeaway
If a health professional is faced with an unusual or challenging physician-patient encounter, the health professional is expected to take notes of this encounter themselves, rather than relying on the notes of a trainee or colleague.
