Many of us neglect to consistently keep dispensing records and there are others who skip record keeping, thinking it is not as important as other parts of the job. But keeping detailed records can make our work life much easier, allowing us to work or delegate with greater efficiency and to pinpoint specific pieces of information when we need it.
There are times when a customer is left dissatisfied and records of what transpired can help us work out why they feel that way; it can help us decide whether we have made an error or whether the customer’s decision resulted in them selecting a suboptimal option against our recommendation. The Optical Consumer Complaints Service (OCCS) has encountered cases where record keeping lapses in relation to dispensing have made a case much more complicated to resolve and where missing pieces of information have affected the outcome of a complaint.
Optometrists and dispensing opticians rely on their professional judgement and make decisions based on their knowledge and skills. Customers may sometimes choose to ignore professional advice or they may be dissatisfied with the outcome of their care or with a dispensed product. In such cases a contemporaneous record is invaluable.
The most common complaint the OCCS receives is where a customer experiences non-tolerance of lenses particularly where the prescription and dispense are provided by different practices.
The General Optical Council’s Practice Standard came into effect this April, placing an obligation on registrants to respond to complaints effectively, honestly, openly, politely and constructively. These standards apply to optometrists and dispensing opticians, highlighting the need for good record keeping in all aspects of the profession.
Developing record keeping and complaint policies can help identify where something has gone wrong so you can address any problems and prevent things from going wrong again in the future. An effective policy should act as guidance for you and colleagues, cutting down on mistakes in the future and helping to understand what should happen when an unfamiliar situation occurs. In addition, handling complaints well demonstrates a commitment to offering the best possible care to your patients and so can have a positive commercial effect. It is also important that a customer’s dissatisfaction is acknowledged even when it is not as a result of a mistake; acknowledging dissatisfaction is not an admission of error and may help to resolve a complaint. Keeping a record of any concerns will smooth communication with a customer and make them feel their concerns are being addressed.
Having robust record keeping and complaint policies should help an organisation deal with complaints effectively in house, but there are times when a complaint cannot be resolved and impartial mediation by the OCCS may be necessary. The OCCS will only mediate when a complaint has already been made to the practice and will request records related to the complaint from the practice; it is important these records are thorough so both sides can be offered pertinent advice. These records are used to substantiate what advice was given and what action was taken.
Good dispensing records are of considerable value to the management of any potential complaint and can help to protect you, showing the proper steps to protect, safeguard and inform a patient were employed. Their primary purpose is to document the assessments underlying the different stages of the consumer’s journey, serving to reconstruct events at a later date. This is vital as many months may elapse between visits, staff may move on from the practice, or events may simply not be recalled. Records need to be kept as if something has not been recorded then it can be assumed it did not happen.
The GOC’s Practice Standard offers guidelines on record keeping (Standard 8) which will make it easier to resolve disputes in the first instance or through OCCS. Records should be made at the time to ensure accuracy and must be:
- Legible and intelligible so the meaning can be easily and fully gleaned.
- Complete so no relevant information can be missed.
- Specific so the meaning can be readily interpreted.
- Signed and dated so the series of events can be properly understood and it can be verified that appropriate timescales have been followed.
- Any abbreviations should be universally understandable and not open to misinterpretation. They should be written with care as a slip of the pen can easily change the meaning of an abbreviation. Certain abbreviations are unacceptable, eg coded exasperation, invective or sarcasm.
Complete records should cover telephone contact, written contact and patient visits to the practice, noting any queries, complaints or dissatisfaction expressed by the patient as well as advice offered by the practitioner. When a patient has declined advice then this should also be noted, such as advice against a particular choice of frame and why this advice was offered. Any paperwork the patient is required to sign should be included in these records.
Rather than being an unnecessary administrative task, record keeping is a vital part of the profession that helps keep us informed of our interactions with our customers and keeps track of their decisions which can be harder to recall than our own assessments. Most importantly, comprehensive records can help us to do our job better but, should a dissatisfied customer make a complaint, can also make sure it is resolved fairly and without unnecessary delay.
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Reducing varifocal non-tolerance
Sue Clark is a qualified dispensing optician and resolution manager at the OCCS