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Last week I was having a conversation with Charlotte Stilwell (long time mentor, heroine and friend of mine)

She had asked me to look at some of her case notes from that day’s clinical work in the practice to check if I thought they were ok. Me being a ‘medicolegal expert’ in her words! Perhaps I used to be a ‘medicolegal expert’ but not anymore.

I did look at the notes but I didn’t have to.

This is Charlotte Stilwell!

I knew they would be near perfect and I also knew they wouldn’t be perfect.

It’s not possible to write perfect case notes because perfection is in the eye of the beholder and almost certainly if someone has to look at your case notes they will find a deficiency or a gap or a variation from what they would do.

This is in effect what happens when people look at case notes in medicolegal work and they apply their bias and their style to their interpretation of the notes they have written.

Some people think you haven’t written enough, some think you’ve written too much, some think you’ve missed a subject here or there and some think you haven’t but you’ve missed it there.

Like it or lump it, you have to get over it.

The law – and by ‘the law’ I mean compliance and regulation – is fluid and flexible and open to opinion. By the time a complaint about your work reaches the stage where other people are scrutinising your case notes you have to suck it up and understand that they will never be perfect.

It’s worth remembering though that they don’t have to be perfect, they have to be ‘acceptable’. It is a loser’s game to chase perfect case notes because you’ll spend more and more of your life (in a dentist’s case, usually time they would spend with their family or outside of work in some other way) completing reams and reams of case notes that will never, ever be read.

Better to accept the fact that should the worst-case scenario arise, you will be questioned on a small scale for minor deficiencies in your case notes, the same as everybody else.

I have never met a clinician who writes perfect case notes (the best I ever saw I think were Professor John Gibson’s – but that was when he was a junior) and the reason I’ve never seen perfect notes I think is because they don’t exist.

Perfection exists in nothing and soon, I hope, regulation and the law will catch up to the fact that perfection is not possible.

Blog Post Number: 1919