Episode 27 - Why taking great notes is your most effective defence against claims and complaints - best practice for clinical note-taking
Confidence To Thrive - a podcast for ambitious healthcare practitioners and entrepreneurs
<p>Defensible Note-Taking for Functional Medicine and Private Practice: Reducing Litigation Risk</p>
<p>In this episode of Confidence To Thrive, Owlicity directors Christopher Cloke Browne and Roger Houston discuss best-practice note-taking for functional medicine and private healthcare, focusing on defensibility against negligence claims. </p>
<p>They explain how poor notes increase litigation risk, especially when clinicians rely on hearsay and emphasise documenting key clinical decision-making, options discussed, and quantifying risks rather than being overly discursive. </p>
<p>They discuss drivers of poor note-taking to be factors including time pressure, focus on patient attention, “doctor knows best” benevolence, and commercial pressures in private practice, including inappropriate deference to patient requests. </p>
<p>The hosts recommend peer review in larger practices, using brief repeat-entry notes to evidence ongoing communication patterns, and leveraging technology such as secure audio recordings and AI-assisted documentation, while cautioning about accuracy, GDPR, and cybersecurity.</p>
<p><b>Episode time stamps</b></p>
<ul>
<li>00:45 How great note-taking kills claims in their tracks</li>
<li>04:06 Why most practitioners skip notes</li>
<li>07:37 The private vs NHS gap</li>
<li>11:33 What to include in your notes to make them defensible</li>
<li>15:56 Team standards and the value of peer review</li>
<li>17:28 Identifying patterns and high risk patients</li>
<li>24:07 Using AI for note-taking</li>
</ul>
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