The Locum's Note
Daniel is a third-year medical student on a two-week GP placement in Cork. During a consultation he observes the locum GP, Dr Hayes, type 'no chest pain' into the patient's record. The patient, a 68-year-old smoker with a three-day history of sharp pain on inspiration, had actually said the pain was 'sharp when I breathe in'. Dr Hayes moves on without examining the chest. After the patient leaves, Daniel mentions the discrepancy to the practice nurse, who says: 'He's only here for a fortnight and the partners are desperate for cover. If you flag it, you'll be the student who made trouble. The patient is back on Friday anyway.' Dr Hayes's note also fails to record the patient's temperature, which the healthcare assistant had measured as 37.9°C. Daniel has a meeting with his clinical supervisor, one of the partners, the next morning.
1. What is the most appropriate first action for Daniel, and why?
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First, Daniel should write a factual, dated note of what he saw and heard: the patient's exact words, the entry 'no chest pain', the absence of a chest examination, and the temperature of 37.9°C. He should not alter Dr Hayes's entry. He should then raise the matter with his clinical supervisor at the start of the next morning's meeting, before other business. The reasons are that the record is inaccurate in a way that could mislead the next clinician, the patient has symptoms suggesting a significant respiratory problem, and Daniel's position as a student requires him to report through the proper route rather than edit records or challenge the locum in front of the patient. The nurse's advice is a prediction about consequences, not a clinical argument, and it does not transfer responsibility away from Daniel.
2. Identify the two conflicting pressures and explain which should take priority.
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The two pressures are collegial loyalty and the duty to protect the patient and the integrity of the record. The first is real but conditional: the practice is short-staffed, Dr Hayes is temporary, and Daniel fears being labelled a troublemaker. That concern is about Daniel's comfort and the practice's staffing convenience. The second is unconditional and owed to the patient, who cannot see the record and does not know it is wrong. Priority therefore goes to the patient. A useful test is to ask which harm is reversible: an awkward conversation can be repaired, whereas a missed diagnosis or a record that misleads the Friday clinician may not be. The nurse's warning describes a social cost, not a reason to accept a clinical risk.
3. The nurse says the patient is back on Friday. How, if at all, does that change the decision?
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The Friday appointment reduces but does not remove the risk. Three days is long enough for pneumonia or another serious cause of pleuritic pain to progress, and the record the Friday clinician reads will say 'no chest pain', which may lower their index of suspicion. The appointment also does not correct the false entry, so the error persists for future consultations and for audit. The correct decision is therefore unchanged: report now. If anything, the scheduled follow-up gives Daniel a clear opportunity to ensure the correct history is available before that appointment, rather than a reason to wait. Waiting would convert a correctable documentation error into a three-day delay in the patient's care.