In this episode we talk to Dr Peter Edwards who is a GP and academic clinical fellow at the Centre for Academic Primary Care at the University of Bristol Medical School.

Paper: Factors affecting the documentation of spoken safety-netting advice in routine GP consultations

https://doi.org/10.3399/BJGP.2021.0195

Previous research has provided qualitative insights into how GPs document safety-netting advice and there have been quantitative reports of the binary presence or absence of safety-netting in medical records. This is the first study to undertake a detailed analysis of the content of documented safety-netting advice and make objective comparisons to what was spoken in recorded consultations.

GPs more frequently documented their safety-netting advice if it was specific (e.g. “I’d want you to come back if you start coughing up horrid coloured stuff, greeny-browny, or if you start coughing up any blood, or if you feel more short of breath.”) rather than generic advice (e.g. “any problems let me know”), for a new problem, and for problems that were the entire focus of a consultation.

These trends in GP documentation practices highlight that certain consultations, such as those where multiple problems are assessed, may represent a higher medico-legal risk to GPs due to incomplete documentation, and these potential biases should be considered in medical-records based research.