An audit of record-keeping in a domiciliary settingone year on

As quality assurance and clinical governance continue to remain high on the agenda within the optical profession, audits are becoming more commonplace.
Healthcall Optical Services is the largest provider of domiciliary eye care services in the country, performing in excess of 100,000 eye examinations annually. The company continues to strengthen its development of clinical governance in several ways, one of which is the clinical audit of record-keeping.
Its first audit took place in the latter part of 2003, which led to an article on record-keeping in the domiciliary setting that was published in optician (February 27, 2004).
In that article, we outlined the reasons why we chose to audit, why good records are essential for all (not just those practising in domiciliary work) and described the way in which the audit was performed and how the results had been interpreted.
In this article, we discuss the second annual audit conducted in autumn 2004 and hope to demonstrate how the audit process can improve record-keeping

importance of good records
The General Ophthalmic Services regulations are currently under review including those for domiciliary eye care.
Following the launch of the code of practice for domiciliary eye care providers in December 2004, the clinical standards by which practitioners are expected to provide eye care in all sectors of the profession are rising. This increase in clinical standards includes the element of good record-keeping.
In this litigious age, where consumers can and will complain about anything and everything, it is vital that all practitioners are fully prepared to handle complaints. It has been mentioned in various articles that the record card can be our only defence in a case of complaint; we should all, therefore, strive to include as much detail as possible for this reason, if for no other.
We have all read of disciplinary cases where the patient claims that they reported the presence of a particular set of symptoms to the practitioner, and the practitioner denies that to be the case.
In the absence of written evidence, the GOC may have the task of deciding which version of events to believe. A comprehensive record, including all symptoms reported and all advice given by the practitioner to the patient, will help to combat this problem, should the worst happen.
It is sobering to remember that it is not only 'bad' practitioners who find themselves the subject of a GOC disciplinary hearing; many of those who experience this distressing and devastating situation are ordinary, everyday practitioners, trying to do their best for their patients.
All records should be legible, and any abbreviations used should be those in common use within the profession. It is important to remember that you may not be there to interpret your writing if the patient has a problem or query in the future, and someone else may have to deal with it.
Also, a different practitioner may perform the next examination on the patient, and it will be necessary for them to be able to read and understand your record, in order to provide good continuing care.
Companies who employ a variety of locums on a very short-term basis can find even simple complaints difficult to deal with if the record is less than comprehensive, since the examining practitioner is no longer available to interpret their record. Your absence from the practice does not reduce the responsibility you bear to the patient.

Background
Following on from Healthcall Optical Services' first audit of clinical records in 2003, the audit process has been continual throughout 2004. During those 12 months, all new practitioners have had their records audited within the first two weeks of being with the company, regardless of whether they came on an employed or locum basis.
Most of those whose records were examined had their results included in this 2004 audit.
A very few were excluded, as some of them have been locum optometrists who have only worked for Healthcall for a very short time, sometimes only a single day, on a temporary basis. These audits have been kept on file so that we can consult them if these optometrists should work for Healthcall again at a later date.
The report is based on an audit of records made by all practitioners working for Healthcall during the month of April 2004, and any locums from other months who happened not to be working for the company during April, but regularly supply locum services. As with the 2003 audit, an arbitrary date was chosen.
Since the previous audit, in order to further assist improvement in record-keeping across the company, Healthcall has introduced a protocol for record-keeping, formulated by our Professional Standards Committee and based on the guidelines from the College of Optometrists.
This protocol has been distributed to all practitioners and is structured in such a way that adherence to it will improve the quality of an individual's record-keeping and so the result they achieve in the audit. It is provided as part of their personal development plans.

Why audit?
In a company such as Healthcall, employing the services of a large number of optometrists and OMPs at any given time, it is physically impossible to continually observe the quality of the performance provided by every practitioner.
Few companies will have either the resources or the inclination to observe their practitioners at work on a regular basis, by 'sitting in' on the eye examination. Despite this, it is, nevertheless, important that practice owners have a method that can be used to evaluate the performance of their employees and locums; they are providing services in the company's name, and any business will stand or fall by its reputation.
Clinical governance is here to stay, and clinical audit is one of the mainstays of any CG strategy.
Record audit provides an effective, objective method of analysing performance, and, while it is true that a poor record does not necessarily represent a poor examination, the two can be considered to go together in many cases.
An audit is not something to fear; it should be seen as a constructive process, through which improvement can be made as part of a personal development plan. At Healthcall, all of our audited practitioners are provided with a report on their performance, and on how their performance compares with those of all the other practitioners audited.
This provides a competitive element to the process, each wishing to write better records than their colleagues. All of our practitioners have been provided with a personal development plan, and they are encouraged to regard the audit as a vital part of their continuing development.
Audit need not be a process that is imposed by a 1984-style 'Big Brother'; self-audit is both a useful and revealing exercise, not only for those who are sole-practitioners, but also for those of us in larger companies, and it is a sensible addition to any formal audit process. The formulation of a score-sheet, similar to the one used by Healthcall, and subsequent marking of one's own records in an honest and objective manner gives an indication of how the records would be viewed by one's peers.
It is too late to change when the PCT requests copies of your records following a complaint, or when the GOC begins an investigation; we should all be aiming for the perfect record card now - starting today.

Other audits
The range of processes that can be audited extends to cover the majority of our work as practitioners.
Healthcall has audited not only the clinical record-keeping within the company, but also the clinical routine used by our practitioners and our dispensing teams. Dispensing ratios, accuracy of orders, the frequency of use of different lens types and so on have all been analysed, and the results have been used to improve the quality of service we provide to our patients.
Auditing is an extremely effective tool in striving for clinical excellence.

Method
The method of audit used was the same as that in 2003, with one small difference.
In 2003, 20 records were audited from each practitioner; in 2004, 10 records were used for any practitioner who had been included in the 2003 audit and 20 records from those who had not.
The score sheet was the same one as used in the 2003 audit (Figure 1). There were, again, 25 marks available for every record audited, one mark for each of 25 points considered by Healthcall's Professional Standards Committee to be vital inclusions on a good record; examples of included points are:

 Ocular history
 Symptoms
 Medication
External examination
 Internal examination
 IOP - (indicating the time of the reading and instrument used, for the full mark)
Motility
Appropriate prescribing, etc.

The Professional Standards Committee members, each of whom is the lead clinician for their branch, were sent photocopies of the records they were required to audit, along with a score sheet and a set of guidelines to help them in the marking process (Figure 2). In some cases, half marks could be awarded, dependent upon the amount of clinical information recorded.
The Professional Standards Committee members audited each other's records; in all other cases a lead clinician from another branch, who did not know the author of the records personally, was chosen to be the auditor.
The auditors were given a deadline for completion of the marking, and then all of the score sheets were returned, in order for the results to be analysed.

Reporting results
The result for each individual record was expressed as a percentage of the 25 marks that could have been scored. The overall result of each practitioner was expressed as an average of all the individual marks awarded to each of their records.
This overall result for each practitioner was used to calculate a 'National Average' score for the company as a whole, and all of the individual results were compared with this.
In addition to that, since this was our second annual audit, for those practitioners who had been included in both audits, their results were also compared with those they achieved at the last audit, and the overall national result was compared with that of the 2003 audit.

Results analysis
Of the practitioners audited, two-thirds had been included in the 2003 audit and the rest had joined the company subsequently. Considering those for whom this was their second annual audit, almost 90 per cent of them improved upon their 2003 score (Figure 3).
Some practitioners made huge improvements upon their previous score, but in some cases, there was little room for any improvement to be made. Anyone who had a near-perfect record last time could not be expected to improve by very much this time.
We now have several practitioners who have achieved very close to a 100 per cent score. As in the last audit, it was noted that some practitioners still continued to lose marks for what might be considered to be minor omissions, such as pupil reactions, previous Rx, patient advice and so on. Poor legibility was still apparent on some records.
The audit process has led to further design improvements to the style and content of Healthcall's record card. This should in turn produce more accurate and complete record-keeping and therefore hopefully, a further improvement in the next annual audit.
As already noted, the final results have been expressed both in terms of the position of each practitioner in relation to the other practitioners within their branch, and in relation to all the other practitioners in the company.
An average score for each branch was calculated, and this has been used to express a league table for all of the branches, further increasing the competitive element of the audit.

improved performance?
In the 2003 audit, as already mentioned, a 'national' average score was calculated. This national average has been used as a baseline with which subsequent audits can be compared.
The aim in 2003 was to try to encourage all of the practitioners to attain at least that average score in the future; some of the practitioners audited in 2004 were, of course, being audited for the first time.
Of the practitioners audited in this report, almost 75 per cent of them achieved the goal of scoring at least the 2003 national average score. This, in turn, increased the national individual average score by almost 5 per cent.
We consider this to be conclusive evidence that the audit process does improve the quality of practitioners' record-keeping.

The Future
At Healthcall, the audit is here to stay; it forms the linchpin of our clinical governance strategy, and is an invaluable tool in personal development.
In time, we expect to expand and modify the current score sheet to include, for example, a more comprehensive method of scoring the internal examination. Any practitioner who comes to work for Healthcall is now aware that their records will be audited and the company expects the best performance from them.

Summary
In conclusion, it is necessary to produce good case records for several reasons.
These include them being a document to support the eye examination, showing exactly what tests were undertaken (and reasons why some tests were omitted, if appropriate) and the outcome of each; to comply with clinical governance and to allow any subsequent practitioner to easily interpret the state of the patient's visual system at the time of the examination.
The optometric profession is ever-changing and as practitioners we too must change to maintain the level of standards that are expected of us.
As the hackneyed phrase goes: 'If you didn't write it, you didn't do it'. It is difficult to understand why, in the 21st century, we still have some practitioners who keep records in the way they did 20, 30 or even more years ago.
Clinical audits are becoming more commonplace within the profession and, as the results of Healthcall's second audit clearly show, they can make an impact on improving the standard of record-keeping - the very thing they have set out to achieve!

Acknowledgements
Jayne Rawlinson, managing director of Healthcall Optical Services; members of Healthcall's Professional Standards Committee; Eileen Reid and Toni Watson, Northern and Southern regional managers Healthcall Optical Services.

 Dawn Roberts and Arif Ladha are clinical directors for Healthcall Optical Services' Northern and Southern regions respectively. Their records were audited along with all the others