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According to Gerda Goldinger, head of legal services at the Association of Optometrists, practitioners need good, legible notes because if there are ever any questions raised, the practitioner's memory is not always sufficient. And, she says, the records practitioners are expected to keep are becoming more and more detailed.
'The world in which we operate is becoming more litigious, and standards of record keeping have changed in the last 30 years,' she says. 'Today's optometrists must be aware that they may have to keep more detailed records than was sometimes the case 30 years ago. What was acceptable back then may not be today.'
When questions are raised about a practitioner's fitness to practise and referred to the General Optical Council, the first step taken by the investigation committee is to scrutinise the patient records. This is done by practising clinicians. Incomplete or poor patient records can make claims of impaired fitness to practise difficult to defend and at the investigation committee level may show a prima facie evidence of impairment. If a problem arises, and records show the relevant tests were carried out and the results, lawyers for the GOC must demonstrate the tests were carried out incompetently, or that subsequent actions were incorrect, to prove impaired fitness to practise. If the records do not show relevant tests or results, lawyers do not have to demonstrate incompetence, but instead that 'beyond all reasonable doubt' the tests were not conducted. While it is not always automatically assumed that if a test was not recorded, it was not performed, if there is no evidence it is easier for lawyers to prove.
Litigation aside, practitioners need to produce records which can be easily understood by other professionals. Should the patient move or be referred for specialist treatment, other practitioners must be able to read, follow and understand the patient's history and treatment.
Good records
It is safe to assume that the days of jotting down NAD (no abnormalities detected) on record cards are over. While there is no set format on what a good record should look like, the various professional bodies have issued plenty of guidance on what should be included. Put simply, a good record involves writing down what the patient said, what the practitioner said, what was done, what was found - and equally, what was not found - conclusions, actions taken and any advice given.
'In general, the more information, the better. What absolutely has to be there is all of the basic patient information - name, address, dates of birth, medical and family history,' says Nick Rumney, chair of the GOC Standards Committee and the Revalidation Committee and member of the GOC Investigation Committee. 'Existing visual status ought to be recorded, and that should include unaided vision and corrected visual acuity, distance and near and both monocular and binocular. The lack of monocular near acuities robs the practitioner of vital clinical information as well as a line of defence if something goes wrong.
'Questions asked ought to be recorded, even if they are answered in the negative. The defence for not conducting a particular test is frequently that, in the clinical judgement of the practitioner, it was not necessary - but the records often show no such evidence that the test was even considered and that judgement made.'
He also encourages optometrists to be especially thorough in questioning a patient on their symptoms and warns against taking symptoms descriptions at 'face value'. 'Practitioners must work out exactly what the patient's symptoms are before noting them down. For example, some patients might describe blurred vision as double vision. Patients can say strange things and these need to be made clear for the records,' he says.
Diagrams, he notes, are also helpful to include in patient records. While marks are never awarded for artistic merit, a simple circle marking lesion size and location is a quick and easy descriptor and demonstrates the feature was observed.
It is important, continues Rumney, to ensure that the reasoning behind any clinical decision is evident, and if it is not, explanatory notes need to be made. Like a story, a record card should have a beginning, middle and end, with a clear link between the reason for the patient's visit and the outcome of the visit. 'Very often the problem is written down, but there is no train of thought which leads you through the process,' he says. 'Often you see that a person has attended because they have sore eyes and the end result is a new pair of spectacles. The reasoning behind this is not clear, the reason for the visit has not been linked to the outcome.'
Take the time
One of the biggest factors which often hampers practitioners in producing complete records is a lack of time. Unlike dentists, who often have a note-taker sitting in the consulting room with them, optometrists must do everything themselves. And certain working environments which place pressure on the optometrist to see patients as quickly as possible do not help the situation. Nor, says Rumney, does the existing NHS General Ophthalmic Services contract. 'It is an insane contract. It prompts practitioners to churn through their patients, as they are not getting paid enough for their time - so they attempt to fit more patients into smaller segments. The pressure is really on them to fit more and more patients in an hour,' he says.
Emergency appointments - often squeezed on to the end of a busy day - are often the cases where problems arise. Rumney suggests that if a practice decides to see patients on an emergency basis, this must be built into the management of the practice. 'They are often the last appointment, the practitioner is often desperate to go home and they think they will just write up the records in the morning - but they forget,' he says. 'At my practice we leave six emergency appointment slots every day. Three of them can be booked the day before - people can telephone and ask for an appointment - and three can only be booked on the day. These emergency slots are booked every single day, it is a rare occurrence that one of them is left free. We manage emergency consultations as part of everyday practice so that they don't add extra time pressures to staff.'
Improving practices
Auditing patient records is an important process in ensuring bad practices are identified and remedied. The College of Optometrists runs valuable CET-accredited peer review groups which allow practitioners to meet and compare record cards. And for optometrists working in group practices, it is worthwhile approaching colleagues and asking them to look over their record cards for any gaps in information. Optometrists working single-handedly, however, do not have this luxury and may also find it difficult to attend peer review groups. But Susan Blakeney, consultant optometric adviser to the College of Optometrists, notes that a self-audit is still possible, and is a valuable exercise to undertake.
'The best way to do a self-audit is to decide what you want to see on your records. So you're looking for the basics, the key components of the sight test and the main findings. You need to think about what is desirable,' she explains. 'Once you have that list, take a random sample of records and go through them closely. Look at what is there and what is missing and make a note of it. It might be that you find everything is in order, but if you don't, you need to take steps to remedy the situation.'
One way of ensuring patient records are correct is to discuss them with the patient at the end of the consultation, she suggests. 'Not everyone is perfect and it is very easy when talking to a patient to forget to write something down,' she says. 'Something I do, at the end of a consultation, is read out verbatim what has been written down on the record card. This not only reassures the patient that you have been listening to them, but they will also tell you if they hear something they believe is wrong. They will correct you. And always talk through any prescription with the patient at the end.
'Record keeping is certainly an area where practitioners could improve. Some practitioners' records are lovely, some are appalling and most are somewhere between the two. Time is always very precious in that consulting room but taking a few minutes to complete a full and accurate record is time well spent - especially if someone comes back to complain.'