Originally Posted by Unregistered

Hi guys, would like to hear the opinion of some of the seniors in this chat, particularly those involved in medicolegal work.

Is it true nowadays that what you document on the consult note or rounding note is actually more important than what you actually tell the patient?

A bit of context: currently a junior MO mopexing, currently rotating through surgical posting, also done medical last posting (still undecided on my career).

For example, nowadays, when we are asked to consent someone for a procedure (e.g tkr/wound debridement), our consent is 2 pages long, explaining all the risks, benefits, alternatives. It is easy as all these is templated. (I.e if you type .tkr and everything comes out). I can assure you that when we mos consent or even when the consultant themselves consent in clinic, not all the info is explained to the patient. Is it true that as long as we document, even if it is not said to the patient or the patient can't understand it's also ok if issues arise in the future?

I have highlighted to my consultant before, that for some of my patients (esp the older ones) they actually don't fully understand what I say, they have no known dementia, but can't really remember, retain and repeat the info that I have given them (which I believe it is part of determining mental capacity), but my consultant just say as I long as I document in detail (i.e the template with all the info) and patient sign the consent form then it is ok, don't worry.

Similarly, if pt refuse a particular investigation/specialist referral, we will also document a whole long essay about the potential serious things that can be missed, without actually telling the patient all these things (sometimes we just say a bit, but document a lot more). This is true for both surgical and medical postings; sometimes the reg/con themselves will actually even overwrite our note after rounds and add in even more stuff that we didn't really tell the pt, or stuff that I feel the pt don't really understand.
They will also sometimes change the wording/phrasing of our documentation, even though that is not what we said.
- A typical example will be, e.g the cxr for a old uncle shows a small lung nodule, we will physically tell the uncle, don't worry, the nodule is small, don't need CT, don't need investigate further.

However when we document, they will change it to "cxr shows lung nodule, discussed CT thorax for further evaluation, patient not keen, understand risks of missing malignancy. " ; Which is kind of not what we tell the patient?

I guess I am still very junior and will never understand the naunces of these kind of things. Just wondering if that is the way going forward, (i.e documentation more important than the actual communication), but I don't know, it just feels wierd that we are twisting our words and documenting things that are not really said or done...

Would appreciate genuine advice/opinion thanks