Report on performance
Scenario 14
Medical records
All medical records for the practitioner were deficient in essential clinical information such as: psychiatric presenting complaint, history, diagnosis and management plan; inadequate if any details of mental state examination, methadone dosage, methadone treatment goals and psychiatric management plan.
When asked about the difficulty he had reading a record and considering the limited entry, the practitioner stated:
'It was a very busy day. One has to think fast, work fast, cover a lot of ground fast--- The notes are made at the end of the consultation or sometimes just briefly through the consultation.'
No prescription was attached to the back of a patient's file and the practitioner agreed that there was no way another doctor could know what dose, and for how long, and how many take-aways were prescribed during the consultation.
When asked what the entry 'seems okay, well' meant, the practitioner stated:
'Well, that was probably the equivalent of saying clear mental state examination.'
When asked about a script that was faxed to the chemist, in particular what medication was prescribed (because there was no record of this), the practitioner stated:
'It would have been a script for methadone because he would not have wanted anything else.'