Summary
There was substantial variation in how often GPs documented the safety-netting advice they had given to patients, which ranged from no documentation to almost nine out of every 10 problems.
GPs were more likely to document their spoken safety-netting advice when assessing new problems, when they had verbalised specific rather than generic safety-netting advice, and when only one problem was assessed in the consultation. In consultations where more than one problem was discussed, the later a problem was assessed, the less likely there was to be spoken or documented safety-netting advice.
Strengths and limitations
To the authors’ knowledge, this is the first study to describe in detail how safety-netting advice is recorded in medical records compared with directly observed spoken advice during GP consultations. The GPs in the archive knew they were being recorded, although they did not specifically know their safety-netting practices would be assessed, minimising potential ‘Hawthorne effects’.24 The exact impact of recording consultations for research purposes on GP behaviours is complex.25 It is conceivable that the findings of this current study may represent GPs attempts at ‘best practice’ and hence overestimate the consistency of routine safety-netting practices. Similarly, it is feasible that there may be unmeasured characteristics more common to clinicians who self-selected to be video-recorded for the archive, such as confidence in their standard of practice, which may again suggest the current findings would overestimate the consistency of practice in the real world.
This was a secondary analysis of a pre-existing dataset of face-to-face, adult patient, routine UK GP consultations only; the sample size was fixed and not generated based on a power calculation. The small sample size and the lack of representativeness of this sample — 295 adult consultations (87.5% self-reported white ethnicity) with 23 GPs (all white ethnicity) from 12 practices in the West of England — may reduce the generalisability of these findings to other settings. Indeed, even in this small sample the authors observed large variation between GPs. The consultations in the archive were recorded in 2014–2015 and contemporary practice may have changed. Finally, because of the cross-sectional nature of the study design, it was not possible to tell if patients had previously been given safety-netting advice for the same problem.
Comparison with existing literature
The GPs in this study often failed to document safety-netting advice, and were less consistent at doing so than primary and secondary care healthcare professionals in studies measuring safety-netting when managing feverish children sent home.7 This is not unexpected owing to the potentially serious nature of feverish illnesses in children and specific guidance that safety-netting advice should be given.26
GPs in the current study were more likely to document specific safety-netting advice when given, which may be more pertinent to patients as the usefulness of generic safety-netting advice has been questioned from a patient’s perspective.27
This study reports that in under half of problems (99/242) where safety-netting advice was given it was also recorded in the medical records. This is 10 fewer problems than reported in the previous study undertaken by the same group.14 In the current study, coders assessed medical records in isolation and did not take into account what was verbalised. For example, one GP verbalised ‘So if you’re getting indigestion pains, coughing up blood, or your stool is very dark and black and sticky, you must stop the naproxen and come and see me straight away’ but only documented ‘discussed possible S/Es [side effects]’. In this current study, these episodes were not coded as documented evidence.
The UK is reported to have an average consultation duration lower than many economically comparable countries.28 It has been reported that on average, GP consultations contain 2.5 problems and only increase by 2 min for each additional problem raised.17 This may not be sufficient time to comprehensively assess, safety-net, and document all problems. The findings in this study suggest patterns of prioritisation in documentation of both clinical problems and safety-netting advice that may be a response to such time pressures.
Implications for research and practice
The finding in this study that over half of safety-netting advice for problems raised in routine GP consultations goes undocumented highlights that retrospective reviews of medical records16 are likely to under-report the frequency of safety-netting advice given in primary care.
Biases in GP documentation practices such as being more likely to document for new problems, when only a single problem was discussed, and when specific safety-netting advice is given (Table 5) may also have an impact. However, as similar associations were found between altered frequencies of safety-netting advice and key variables (Table 6) when comparing spoken with documented advice, large studies of medical records are still likely to be a good platform for researching safety-netting behaviours but should be interpreted with caution. Medical records have the advantage of being routinely collected, and large anonymised datasets for research purposes are easier to create and access than comparable datasets of video-/audio-recorded consultations.
The medical notes edition of the coding tool (SaNCoT) used in this current study was much quicker to use and had a higher level of coder agreement than the more complex observational coding of recorded consultations (κ = 0.87 versus κ = 0.66).3 As such, it is likely to have greater utility in everyday GP work to audit local clinical practice and is available freely.21 The fastest and least time-consuming method would be an automated search of documented safety-netting advice.
Automated searches remain limited at present as most advice is currently recorded as free text and not coded. However, the use of safety-netting templates, with searchable codes may in part address this and is under evaluation.29 Such searches could inform interventions seeking to identify and minimise unwarranted variation in practice.30
With the rise of telephone and e-consulting because of the COVID-19 pandemic, telephone texting systems with pre-defined templates that automatically insert and code into medical records may offer an avenue for improving documentation and patient access to written advice, for which there is patient demand.7,31 Those with low literacy skills have voiced a preference for an audio–visual format of safety-netting,32 which lends itself to smart phone messaging. Texting patients safety-netting advice has been found to be acceptable to GPs but more patient-focused research is needed.33 However, adopting this into routine practice for all patients may contribute to the inverse care law,34 where those without access to a working mobile/smart phone or with health literacy issues could receive a lower quality of care.
This study, and others,15,17 evidence a common disparity between what is said and what is documented in primary care consultations. This potentially leaves those GPs whose documentation is incomplete vulnerable to challenge regarding their practice. Routine audio-recording of all consultations offers one objective avenue for resolving disputes based on this incongruity and is already occurring for many telephone encounters.
Although recording has not been widely incorporated into face-to-face consultations, some patients are already openly and covertly recording healthcare encounters,35 which are admissible evidence in court.36 Despite existing precedents, recording consultations would require clinician and public support and should aim at reducing GP administration time.
Recent estimates have suggested a ‘substantial burden of avoidable significant harm’ in English primary care, mostly attributable to diagnostic error, medication incidents, and delayed referrals.37 Such findings and the study of patient safety incident reports emphasise how effective safety-netting advice and its consistent documentation may help to minimise patient harm.38
The observation, in this study, that GPs are less likely to verbalise safety-netting advice when more than one problem is assessed in a consultation, and they are less likely to document safety-netting advice they have given, should prompt GPs to consider how safely they can assess and document more than one problem in a single consultation, and this risk should be shared with patients to help manage expectations.
