This series highlights common medicolegal issues in general practice. Written by a team from medical defence organisation Avant, it is based on actual cases with details changed for privacy and some issues summarised for discussion. In this case, an action against a GP who treated a patient for a presumed plantar wart, later diagnosed as an acral melanoma, was successfully defended. It highlights the importance of including clinical descriptors, and possibly photographs, in medical records.
A medical practitioner builds a diagnosis from subjective and objective elements: patient recollection, clinical observation and empirical measurement. Good medical practice also requires making a contemporaneous record, and documenting the observations that led to that diagnosis is crucial. Some practitioners use the diagnosis as a shorthand to indicate the characteristics of a typical presentation. Even in otherwise detailed notes, specific features such as lesions may not be well described. As a recent case highlights, should a diagnosis subsequently be challenged, there are risks associated with not recording the observations supporting the diagnosis.