Question

A junior doctor realises at the end of a busy shift that she forgot to document a critical discussion in which a patient declined an offered blood transfusion after risks and benefits were explained. The patient’s decision has already influenced management. What is the most appropriate action now?

Accepted Answer

Add the entry with the correct current date and time, clearly stating it is a late entry referring to events earlier that day

Answer

Leave the notes unchanged to avoid suspicion of altering records

Answer

Backdate a new entry to the original time of the conversation so the notes look contemporaneous

Answer

Ask a colleague who was present to write the entry and sign it in their name

Answer

Do nothing now and rely on memory if this is queried later

Practice question