IMT - Ethics - Altering notes

Question 1

Altering notes: One of your registrars has asked you to amend an entry in the notes from yesterday in which you documented the patient’s consent for a ward-based procedure.

You have been asked to add in writing that “the risks of bleeding, infection and damage to local structures were explained to the patient who fully understands this”. At the time, you did not think these risks were fully discussed with the patient.

Answer 1

• I (Issues): Informed consent/autonomy, patient safety, professionalism & record integrity (retrospective alteration), potential assault/battery risk if no valid consent
• S (Seek info): clarify exact request + why; was consent taken yesterday (by whom/when)? any harm/complaint? check consent form, check patient capacity
• P (Safety): ensure the patient has valid informed consent before any procedure—if not, pause/postpone and arrange proper consent by an appropriate clinician
• I (Initial): refuse to alter your original entry (would be misleading); explain - professionalism & record integrity issue; suggest the registrar writes a new dated/time-stamped clinical update stating that consent is being re-checked now (not backdated)
• E (Escalate): to consultant in charge / your clinical supervisor (especially if harm, pressure to falsify, or repeated behaviour)
• D (Doc/Reflect): document facts, discussions today and your actions taken ;
• Close: “I won’t retrospectively change notes; I’ll prioritise safe consent, escalate, and truthful document.”

Question 2

How would you escalate or report this situation?

Answer 2

• Start within the team: speak to the registrar privately (fact-find), then escalate to the consultant responsible for the patient/procedure
• If unresolved/serious: involve your clinical supervisor/educational supervisor, clinical lead/clinical director, and local governance / Freedom to Speak Up Guardian as per policy
• If immediate patient risk: escalate urgently (on-call consultant) and ensure the procedure is paused until consent is correct
• Document each discussion

Question 3

Define informed consent.

Answer 3

• A process where a patient with capacity
• Makes a voluntary decision
• After receiving understandable information
• Includes benefits, risks, alternatives (including doing nothing), and chance to ask questions
• Consent can be withdrawn at any time
• Proceeding without valid consent may amount to assault/battery

Question 4

In what scenarios is written consent usually required in hospital medicine?

Answer 4

• Usually for invasive procedures with significant risk (trust policy varies): e.g. surgery, endoscopy, LP, ascitic drain/tap, chest drain, many interventional radiology procedures
• Not usually for low-risk routine tasks: venepuncture, cannulation, ECG, etc.
• Written consent should be taken by the person performing the procedure (or someone appropriately trained/competent)
• Don’t take consent for a procedure you’re not qualified to perform

Question 5

If a patient lacks capacity and a procedure is needed in their best interests, what do you do about consent?

Answer 5

• Do a capacity assessment (decision-specific)
• Optimise communication (aids, interpreter, SALT input if needed)
• Consider if capacity may return and whether the procedure can wait
• Check for Advance Decision/ADRT; if present and applicable, it must be respected
• If no ADRT: proceed in best interests & least restrictive option using the trust process (e.g. Consent Form 4)
• Involve if available next of kin
• Document reasoning

Question 6

How would you communicate risks and benefits of an ascitic tap to a patient?

Answer 6

• Set the scene: private space, sit at eye level, check understanding and concerns
• Explain simply: “We’d like to use a needle to take a small sample of the fluid in your tummy, with local anaesthetic; it takes a few minutes.”
• Benefits: helps identify the cause (infection, cancer, liver disease) and guides treatment
• Risks (plain language): bruising/bleeding, infection, very small risk of injury to organs, and sometimes we may not get fluid and need to try again
• Reassure safety: sterile technique ± ultrasound guidance; invite questions; confirm willingness: “Are you happy to go ahead?”
• Check capacity/voluntariness and document the discussion