Record-keeping audit in a domiciliary setting

Healthcall Optical Services is the largest provider of domiciliary eye care services in the country, performing in excess of 75,000 eye examinations a year. As part of the company's continuing development we recently undertook an audit of record-keeping, within the organisation. In this article we outline the reasons why we chose to audit, why good records are essential for all (not just in domiciliary work), describe the way in which the audit was done and how the results have been interpreted. In this way we hope to demonstrate that any optometric practice, whether domiciliary or high street based, can adopt a similar format and thereby embark on its own audit in an easy and effective manner.

Record-keeping
It has been highlighted by DOCET that one of the basic skills within optometry that causes problems for practitioners is that of producing good case records. In many instances, the first indication that a practitioner's records are not adequate can be when a disciplinary case occurs. Some of the cases brought before the General Optical Council's disciplinary committee can be almost impossible to defend on the basis of the recorded information, since insufficient detail is present. Relying on one's memory or the fact that 'nothing is written, so it must have been normal' is unacceptable and out-dated.
It is well known within the profession that 25 years ago the idea behind record-keeping was to make only a note of something that was considered to be worthy of comment. The recording of negative findings was almost unheard of and the absence of a comment indicated that no abnormality was found Ð a blanket 'NAD' being all that was noted in most cases.
Nowadays, however, things are very different; the absence of a comment on any aspect of the eye examination is interpreted as a failure to perform that particular test. 'If you haven't written it, then you haven't done it' is the modern school of thought and this is also the criterion by which the quality of the eye examination provided is interpreted in a disciplinary hearing by the GOC.
A good case record is our defence should there be a complaint. We live in an increasingly litigious society where patients will complain about the smallest thing and the record card is our only source of information about the examination and its outcome. Many of the recent cases dealt with by the GOC list 'inadequate records' as one of the points being considered.
The form that the record card itself takes is not of great importance, although it is useful to have clearly marked headings to act as reminders of what should be written. A blank card may not encourage the keeping of a full and complete record.
Our professional standards committee developed the patient record card currently used at Healthcall. This committee consists of lead clinicians who have been appointed from their local branch, and they are all practising optometrists. In developing the record card, care was taken to ensure that all aspects of an eye examination were covered, including patient management, advice and referral. The College of Optometrists' guidelines on record-keeping were used extensively. The result is a simple 'boxed' system, enabling the practitioner to easily record clinical data, and ensuring that no aspects of the examination are omitted.
The purpose of any patient record is to remind the practitioner of results, to explain the decisions made by the practitioner with regard to the outcome of the examination, and to provide information about the patient's visual system to any relevant party. Unfortunately, as already mentioned, they are also having to be used increasingly as our best defence against prosecution; in fact, it is fair to say that almost without exception the patient record is our only defence against charges of negligence etc, so it is in our own interests to make sure that it is as detailed as possible.
Primary care trusts (PCTs), the GOC, police, solicitors, counter fraud agencies and the courts may all wish to see the patient record in some circumstances, and we must be able not only to produce the record, but also to defend what is written on it.
There is, unfortunately, no statutory list of information, which should be on the patient record; this makes things difficult for us all. The Sight Test (examination & prescription) Regulations contains details of what should be on a written prescription, but not on the patient record.
The GOS requires that records should be kept for seven years and be 'adequate' and contain 'details of the testing of sight'. But such a vague statement is obviously open to many interpretations. Our best guidance comes from the College guidelines, upon which we based our audit.
Clinical Governance
Another reason why good records are important is in order to comply with clinical governance (CG) requirements. CG is the framework through which primary care trusts and other NHS organisations are accountable for continuously improving the quality and safety of local health services, and promoting excellence in patient care.
Any optometrist who undertakes NHS work is included, and bound by the aims and standards of CG, and, for the present, all are expected to be at least developing strategies to comply.
The Commission for Health Improvement (CHI) is busy auditing the PCTs to investigate its CG strategies, and the PCTs in turn are looking at the optometrists who are contracted by them to provide GOS services. You may have already completed a CG questionnaire about your practice.
Any practice which has received one of CHI's questionnaires, will note that there are seven components on which they are concentrating.

Patient and public involvement
This component includes complaints procedures, questionnaires and information leaflets being made available to the public.

Managing risks
These are systems to monitor and minimise risks to patients and staff, and to learn from mistakes.

Clinical audit
Regular systematic reviews of procedures against defined standards. According to the guidelines, audits should lead to action to address any problems which are identified during the procedure.

Use of information
The systems in place to collect and interpret clinical information and to use it to monitor, plan and improve the quality of patient care.

Staffing and staff management
This covers the recruitment, management and development of staff, including regular appraisals and reviews of performance.

Education training and continuing professional development
This covers the support available to enable staff to be competent in doing their job, while developing their skills, and the degree to which staff are up to date with the developments in their field.

Clinical effectiveness.
This ensures that the approaches and treatments used are based on the best available evidence, eg staff access to relevant literature and/or national/local guidelines.

For the purpose of this article only clinical audit will be discussed, but you can see that there is a certain amount of overlap into some of the other points, which result from the audit process.
As PCTs try to develop CG strategies, we can expect to see changes in the relationship we have with them. They are no longer going to be happy to just leave us to our own devices as they have historically. It is important for us to note that the PCTs have the right to see the original copies of our patient records for many reasons. This includes the post payment verification (PPV) checks, which are already under way. It is sensible for us as practitioners to be ready for this and to be able to produce records that are comprehensive, legible and complete.

Clinical Audit
Healthcall said it wanted to perform the audit of clinical records for several reasons:

It has an ongoing commitment to clinical governance
It wanted to examine clinical standards being provided by its service
It wanted to quantify the differences in standards of record-keeping, with a view to producing a protocol of record-keeping
It is committed to providing a top quality service to patients and to strive to continually develop and improve the service offered.

All of these points seemed to indicate that an audit of record-keeping was the way forward. While the company accepts that a poor record does not necessarily indicate a poor quality of eye examination, it has been shown that the two do go together on the whole. Although Healthcall is a domiciliary company, the audit principles that were used could be applied to any optometric practice.

Score sheet
A score sheet (Figure 1) was designed that contained a list of 25 points, which ensured that all details of the record card, and so the eye examination, were included. The score sheet was divided into five main sections:

Legibility and completeness of record
Completeness of clinical information
Patient consultation
Patient management plan
Patient referral.

It was decided to further divide these sections into sub-sections, since it was felt that some points were more important than others and also because we wanted to ensure that a high mark could not be attained by recording non-clinical information only. A percentage score was given for each section, as well as an overall final score.

Guidelines
A set of guidelines (Figure 2) was produced, ensuring that the marking of the records by the auditors was done in a strictly controlled, consistent and objective manner.

Process
The audit was conducted as follows:

All practitioners working for Healthcall at the time, both employed and locum were audited.
Practitioners had been informed well in advance that an audit was to take place but, naturally, no mention was made of the dates that were to be used in the audit. Subsequently two consecutive dates in July were chosen at random.
Copies of 20 record cards for each practitioner, from the chosen dates, were requested from the local branch office. If any practitioner had not worked on those days, the nearest dates to those selected were used.
The auditors, who were all members of Heathcall's professional Standards Committee, were allocated particular branches to audit; ensuring no one marked record cards from their own branch.
At the beginning of August 2003, the auditors were sent the copies of their allocated record cards, together with a set of guidelines and score sheet for each practitioner's set of records.
The score sheet listed the 25 points that were considered by the professional Standards Committee to be necessary inclusions on a good record. Each point was allocated either one mark for its presence or zero for its absence. In certain cases, such as Point 17 Ð Internal examination, it was recognised that half marks could be awarded, at the auditors' discretion, depending on the amount of clinical data recorded.
Each record card had a maximum of 25 marks available and each individual score was expressed as a percentage of those 25 marks.
The auditors were given one month to complete the task and in September 2003 the results were collated for analysis.

Results
The average percentage mark for the 20 record cards was calculated to be the final score for each practitioner. The average score for each practitioner was used to calculate a 'National Average', against which all the results were compared. The final results were expressed in terms of the position of each practitioner in relation to all the other practitioners in the country.
The individual practitioners' scores were used to give an overall 'branch average' score. The 'branch average' was used to express a league table of results for all the Healthcall branches in the country, eight in all. Every practitioner was informed of his or her results by post. They were also sent a blank copy of the score sheet and set of guidelines to indicate how the marking process was carried out.

Discussion
The audit results showed quite effectively the large spread of individual scores. It was expected that not all practitioners would score the same.
Many who did not achieve optimum scoring lost marks for what might be considered to be minor omissions, such as pupil reactions, previous Rx, patient advice etc. These are things which were probably actually done during the examination, but which have simply not been written down. Even simple things, such as neglecting to put their own name on the record, and whether the patient was given a change of prescription, were found and therefore marks were lost. Others may have written everything required, but not legibly.
The audit is to be an ongoing process, but the mechanics of it are to be slightly different in the future. Each individual practitioner will be audited at least once every year, but we do not intend to audit everyone at the same time routinely. Auditing the records of all the practitioners at the same time was a huge task. Therefore we intend to re-audit those whose scores were the lowest within the next three months. Those who scored highly in the original audit will be audited randomly throughout the year. Any new practitioners working for Healthcall will be audited within the first few weeks with the company.
It is not expected that all practitioners will achieve full marks Ð realistically this would not be possible. However, the company expects its practitioners to strive to achieve a score above the present national average in future audits, through constant peer assessment and support.
Recently, an interesting phenomenon has been noticed as a result of the audit process; those practitioners who have been asked to audit the records of others have all said that the process has improved their own record-keeping. In examining the records of other people, one is made more aware of one's own shortcomings in record-keeping, and so, improvements in one's own records are made. Additional data was gleaned from this audit that has proved particularly useful to the company, however, discussion of this data is outside the scope of this article.
Healthcall, as part of its CG commitment, intends to give full support to all its practitioners in trying to raise the standard of record-keeping, through continuing education, training and appraisals. This will become part of the practitioners' personal development plan. Ultimately, it is hoped that using the audit results as a guide a Healthcall record-keeping protocol will be developed.

Summary
In conclusion, it is necessary to produce good case records for several reasons. These include a document for own defence, should it ever be necessary; 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. The ideology that 'I have always done it this way so why do I need to change' can no longer exist. If the results of a procedure are not on the record card, then it is assumed that the procedure was not carried out. 'If you didn't write it, you didn't do it'.

Acknowledgements
Commission for Health Improvement. Members of Healthcall professional standards committee. Dr Bill Holmes, Nestor Group medical director.
Jayne Rawlinson, managing director Healthcall Optical Services. Special thanks to David Derrington, former professional services manager, Healthcall Optical Services.

Dawn Roberts and Arif Ladha are clinical managers for the Healthcall Optical Services' northern and southern regions respectively. Their records were audited along with all the othersHealthcall Optical Services is the largest provider of domiciliary eye care services in the country, performing in excess of 75,000 eye examinations a year. As part of the company's continuing development we recently undertook an audit of record-keeping, within the organisation. In this article we outline the reasons why we chose to audit, why good records are essential for all (not just in domiciliary work), describe the way in which the audit was done and how the results have been interpreted. In this way we hope to demonstrate that any optometric practice, whether domiciliary or high street based, can adopt a similar format and thereby embark on its own audit in an easy and effective manner.

Record-keeping
It has been highlighted by DOCET that one of the basic skills within optometry that causes problems for practitioners is that of producing good case records. In many instances, the first indication that a practitioner's records are not adequate can be when a disciplinary case occurs. Some of the cases brought before the General Optical Council's disciplinary committee can be almost impossible to defend on the basis of the recorded information, since insufficient detail is present. Relying on one's memory or the fact that 'nothing is written, so it must have been normal' is unacceptable and out-dated.
It is well known within the profession that 25 years ago the idea behind record-keeping was to make only a note of something that was considered to be worthy of comment. The recording of negative findings was almost unheard of and the absence of a comment indicated that no abnormality was found Ð a blanket 'NAD' being all that was noted in most cases.
Nowadays, however, things are very different; the absence of a comment on any aspect of the eye examination is interpreted as a failure to perform that particular test. 'If you haven't written it, then you haven't done it' is the modern school of thought and this is also the criterion by which the quality of the eye examination provided is interpreted in a disciplinary hearing by the GOC.
A good case record is our defence should there be a complaint. We live in an increasingly litigious society where patients will complain about the smallest thing and the record card is our only source of information about the examination and its outcome. Many of the recent cases dealt with by the GOC list 'inadequate records' as one of the points being considered.
The form that the record card itself takes is not of great importance, although it is useful to have clearly marked headings to act as reminders of what should be written. A blank card may not encourage the keeping of a full and complete record.
Our professional standards committee developed the patient record card currently used at Healthcall. This committee consists of lead clinicians who have been appointed from their local branch, and they are all practising optometrists. In developing the record card, care was taken to ensure that all aspects of an eye examination were covered, including patient management, advice and referral. The College of Optometrists' guidelines on record-keeping were used extensively. The result is a simple 'boxed' system, enabling the practitioner to easily record clinical data, and ensuring that no aspects of the examination are omitted.
The purpose of any patient record is to remind the practitioner of results, to explain the decisions made by the practitioner with regard to the outcome of the examination, and to provide information about the patient's visual system to any relevant party. Unfortunately, as already mentioned, they are also having to be used increasingly as our best defence against prosecution; in fact, it is fair to say that almost without exception the patient record is our only defence against charges of negligence etc, so it is in our own interests to make sure that it is as detailed as possible.
Primary care trusts (PCTs), the GOC, police, solicitors, counter fraud agencies and the courts may all wish to see the patient record in some circumstances, and we must be able not only to produce the record, but also to defend what is written on it.
There is, unfortunately, no statutory list of information, which should be on the patient record; this makes things difficult for us all. The Sight Test (examination & prescription) Regulations contains details of what should be on a written prescription, but not on the patient record.
The GOS requires that records should be kept for seven years and be 'adequate' and contain 'details of the testing of sight'. But such a vague statement is obviously open to many interpretations. Our best guidance comes from the College guidelines, upon which we based our audit.
Clinical Governance
Another reason why good records are important is in order to comply with clinical governance (CG) requirements. CG is the framework through which primary care trusts and other NHS organisations are accountable for continuously improving the quality and safety of local health services, and promoting excellence in patient care.
Any optometrist who undertakes NHS work is included, and bound by the aims and standards of CG, and, for the present, all are expected to be at least developing strategies to comply.
The Commission for Health Improvement (CHI) is busy auditing the PCTs to investigate its CG strategies, and the PCTs in turn are looking at the optometrists who are contracted by them to provide GOS services. You may have already completed a CG questionnaire about your practice.
Any practice which has received one of CHI's questionnaires, will note that there are seven components on which they are concentrating.

Patient and public involvement
This component includes complaints procedures, questionnaires and information leaflets being made available to the public.

Managing risks
These are systems to monitor and minimise risks to patients and staff, and to learn from mistakes.

Clinical audit
Regular systematic reviews of procedures against defined standards. According to the guidelines, audits should lead to action to address any problems which are identified during the procedure.

Use of information
The systems in place to collect and interpret clinical information and to use it to monitor, plan and improve the quality of patient care.

Staffing and staff management
This covers the recruitment, management and development of staff, including regular appraisals and reviews of performance.

Education training and continuing professional development
This covers the support available to enable staff to be competent in doing their job, while developing their skills, and the degree to which staff are up to date with the developments in their field.

Clinical effectiveness.
This ensures that the approaches and treatments used are based on the best available evidence, eg staff access to relevant literature and/or national/local guidelines.

For the purpose of this article only clinical audit will be discussed, but you can see that there is a certain amount of overlap into some of the other points, which result from the audit process.
As PCTs try to develop CG strategies, we can expect to see changes in the relationship we have with them. They are no longer going to be happy to just leave us to our own devices as they have historically. It is important for us to note that the PCTs have the right to see the original copies of our patient records for many reasons. This includes the post payment verification (PPV) checks, which are already under way. It is sensible for us as practitioners to be ready for this and to be able to produce records that are comprehensive, legible and complete.

Clinical Audit
Healthcall said it wanted to perform the audit of clinical records for several reasons:

It has an ongoing commitment to clinical governance
It wanted to examine clinical standards being provided by its service
It wanted to quantify the differences in standards of record-keeping, with a view to producing a protocol of record-keeping
It is committed to providing a top quality service to patients and to strive to continually develop and improve the service offered.

All of these points seemed to indicate that an audit of record-keeping was the way forward. While the company accepts that a poor record does not necessarily indicate a poor quality of eye examination, it has been shown that the two do go together on the whole. Although Healthcall is a domiciliary company, the audit principles that were used could be applied to any optometric practice.

Score sheet
A score sheet (Figure 1) was designed that contained a list of 25 points, which ensured that all details of the record card, and so the eye examination, were included. The score sheet was divided into five main sections:

Legibility and completeness of record
Completeness of clinical information
Patient consultation
Patient management plan
Patient referral.

It was decided to further divide these sections into sub-sections, since it was felt that some points were more important than others and also because we wanted to ensure that a high mark could not be attained by recording non-clinical information only. A percentage score was given for each section, as well as an overall final score.

Guidelines
A set of guidelines (Figure 2) was produced, ensuring that the marking of the records by the auditors was done in a strictly controlled, consistent and objective manner.

Process
The audit was conducted as follows:

All practitioners working for Healthcall at the time, both employed and locum were audited.
Practitioners had been informed well in advance that an audit was to take place but, naturally, no mention was made of the dates that were to be used in the audit. Subsequently two consecutive dates in July were chosen at random.
Copies of 20 record cards for each practitioner, from the chosen dates, were requested from the local branch office. If any practitioner had not worked on those days, the nearest dates to those selected were used.
The auditors, who were all members of Heathcall's professional Standards Committee, were allocated particular branches to audit; ensuring no one marked record cards from their own branch.
At the beginning of August 2003, the auditors were sent the copies of their allocated record cards, together with a set of guidelines and score sheet for each practitioner's set of records.
The score sheet listed the 25 points that were considered by the professional Standards Committee to be necessary inclusions on a good record. Each point was allocated either one mark for its presence or zero for its absence. In certain cases, such as Point 17 Ð Internal examination, it was recognised that half marks could be awarded, at the auditors' discretion, depending on the amount of clinical data recorded.
Each record card had a maximum of 25 marks available and each individual score was expressed as a percentage of those 25 marks.
The auditors were given one month to complete the task and in September 2003 the results were collated for analysis.

Results
The average percentage mark for the 20 record cards was calculated to be the final score for each practitioner. The average score for each practitioner was used to calculate a 'National Average', against which all the results were compared. The final results were expressed in terms of the position of each practitioner in relation to all the other practitioners in the country.
The individual practitioners' scores were used to give an overall 'branch average' score. The 'branch average' was used to express a league table of results for all the Healthcall branches in the country, eight in all. Every practitioner was informed of his or her results by post. They were also sent a blank copy of the score sheet and set of guidelines to indicate how the marking process was carried out.

Discussion
The audit results showed quite effectively the large spread of individual scores. It was expected that not all practitioners would score the same.
Many who did not achieve optimum scoring lost marks for what might be considered to be minor omissions, such as pupil reactions, previous Rx, patient advice etc. These are things which were probably actually done during the examination, but which have simply not been written down. Even simple things, such as neglecting to put their own name on the record, and whether the patient was given a change of prescription, were found and therefore marks were lost. Others may have written everything required, but not legibly.
The audit is to be an ongoing process, but the mechanics of it are to be slightly different in the future. Each individual practitioner will be audited at least once every year, but we do not intend to audit everyone at the same time routinely. Auditing the records of all the practitioners at the same time was a huge task. Therefore we intend to re-audit those whose scores were the lowest within the next three months. Those who scored highly in the original audit will be audited randomly throughout the year. Any new practitioners working for Healthcall will be audited within the first few weeks with the company.
It is not expected that all practitioners will achieve full marks Ð realistically this would not be possible. However, the company expects its practitioners to strive to achieve a score above the present national average in future audits, through constant peer assessment and support.
Recently, an interesting phenomenon has been noticed as a result of the audit process; those practitioners who have been asked to audit the records of others have all said that the process has improved their own record-keeping. In examining the records of other people, one is made more aware of one's own shortcomings in record-keeping, and so, improvements in one's own records are made. Additional data was gleaned from this audit that has proved particularly useful to the company, however, discussion of this data is outside the scope of this article.
Healthcall, as part of its CG commitment, intends to give full support to all its practitioners in trying to raise the standard of record-keeping, through continuing education, training and appraisals. This will become part of the practitioners' personal development plan. Ultimately, it is hoped that using the audit results as a guide a Healthcall record-keeping protocol will be developed.

Summary
In conclusion, it is necessary to produce good case records for several reasons. These include a document for own defence, should it ever be necessary; 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. The ideology that 'I have always done it this way so why do I need to change' can no longer exist. If the results of a procedure are not on the record card, then it is assumed that the procedure was not carried out. 'If you didn't write it, you didn't do it'.

Acknowledgements
Commission for Health Improvement. Members of Healthcall professional standards committee. Dr Bill Holmes, Nestor Group medical director.
Jayne Rawlinson, managing director Healthcall Optical Services. Special thanks to David Derrington, former professional services manager, Healthcall Optical Services.

Dawn Roberts and Arif Ladha are clinical managers for the Healthcall Optical Services' northern and southern regions respectively. Their records were audited along with all the othersHealthcall Optical Services is the largest provider of domiciliary eye care services in the country, performing in excess of 75,000 eye examinations a year. As part of the company's continuing development we recently undertook an audit of record-keeping, within the organisation. In this article we outline the reasons why we chose to audit, why good records are essential for all (not just in domiciliary work), describe the way in which the audit was done and how the results have been interpreted. In this way we hope to demonstrate that any optometric practice, whether domiciliary or high street based, can adopt a similar format and thereby embark on its own audit in an easy and effective manner.

Record-keeping
It has been highlighted by DOCET that one of the basic skills within optometry that causes problems for practitioners is that of producing good case records. In many instances, the first indication that a practitioner's records are not adequate can be when a disciplinary case occurs. Some of the cases brought before the General Optical Council's disciplinary committee can be almost impossible to defend on the basis of the recorded information, since insufficient detail is present. Relying on one's memory or the fact that 'nothing is written, so it must have been normal' is unacceptable and out-dated.
It is well known within the profession that 25 years ago the idea behind record-keeping was to make only a note of something that was considered to be worthy of comment. The recording of negative findings was almost unheard of and the absence of a comment indicated that no abnormality was found Ð a blanket 'NAD' being all that was noted in most cases.
Nowadays, however, things are very different; the absence of a comment on any aspect of the eye examination is interpreted as a failure to perform that particular test. 'If you haven't written it, then you haven't done it' is the modern school of thought and this is also the criterion by which the quality of the eye examination provided is interpreted in a disciplinary hearing by the GOC.
A good case record is our defence should there be a complaint. We live in an increasingly litigious society where patients will complain about the smallest thing and the record card is our only source of information about the examination and its outcome. Many of the recent cases dealt with by the GOC list 'inadequate records' as one of the points being considered.
The form that the record card itself takes is not of great importance, although it is useful to have clearly marked headings to act as reminders of what should be written. A blank card may not encourage the keeping of a full and complete record.
Our professional standards committee developed the patient record card currently used at Healthcall. This committee consists of lead clinicians who have been appointed from their local branch, and they are all practising optometrists. In developing the record card, care was taken to ensure that all aspects of an eye examination were covered, including patient management, advice and referral. The College of Optometrists' guidelines on record-keeping were used extensively. The result is a simple 'boxed' system, enabling the practitioner to easily record clinical data, and ensuring that no aspects of the examination are omitted.
The purpose of any patient record is to remind the practitioner of results, to explain the decisions made by the practitioner with regard to the outcome of the examination, and to provide information about the patient's visual system to any relevant party. Unfortunately, as already mentioned, they are also having to be used increasingly as our best defence against prosecution; in fact, it is fair to say that almost without exception the patient record is our only defence against charges of negligence etc, so it is in our own interests to make sure that it is as detailed as possible.
Primary care trusts (PCTs), the GOC, police, solicitors, counter fraud agencies and the courts may all wish to see the patient record in some circumstances, and we must be able not only to produce the record, but also to defend what is written on it.
There is, unfortunately, no statutory list of information, which should be on the patient record; this makes things difficult for us all. The Sight Test (examination & prescription) Regulations contains details of what should be on a written prescription, but not on the patient record.
The GOS requires that records should be kept for seven years and be 'adequate' and contain 'details of the testing of sight'. But such a vague statement is obviously open to many interpretations. Our best guidance comes from the College guidelines, upon which we based our audit.
Clinical Governance
Another reason why good records are important is in order to comply with clinical governance (CG) requirements. CG is the framework through which primary care trusts and other NHS organisations are accountable for continuously improving the quality and safety of local health services, and promoting excellence in patient care.
Any optometrist who undertakes NHS work is included, and bound by the aims and standards of CG, and, for the present, all are expected to be at least developing strategies to comply.
The Commission for Health Improvement (CHI) is busy auditing the PCTs to investigate its CG strategies, and the PCTs in turn are looking at the optometrists who are contracted by them to provide GOS services. You may have already completed a CG questionnaire about your practice.
Any practice which has received one of CHI's questionnaires, will note that there are seven components on which they are concentrating.

Patient and public involvement
This component includes complaints procedures, questionnaires and information leaflets being made available to the public.

Managing risks
These are systems to monitor and minimise risks to patients and staff, and to learn from mistakes.

Clinical audit
Regular systematic reviews of procedures against defined standards. According to the guidelines, audits should lead to action to address any problems which are identified during the procedure.

Use of information
The systems in place to collect and interpret clinical information and to use it to monitor, plan and improve the quality of patient care.

Staffing and staff management
This covers the recruitment, management and development of staff, including regular appraisals and reviews of performance.

Education training and continuing professional development
This covers the support available to enable staff to be competent in doing their job, while developing their skills, and the degree to which staff are up to date with the developments in their field.

Clinical effectiveness.
This ensures that the approaches and treatments used are based on the best available evidence, eg staff access to relevant literature and/or national/local guidelines.

For the purpose of this article only clinical audit will be discussed, but you can see that there is a certain amount of overlap into some of the other points, which result from the audit process.
As PCTs try to develop CG strategies, we can expect to see changes in the relationship we have with them. They are no longer going to be happy to just leave us to our own devices as they have historically. It is important for us to note that the PCTs have the right to see the original copies of our patient records for many reasons. This includes the post payment verification (PPV) checks, which are already under way. It is sensible for us as practitioners to be ready for this and to be able to produce records that are comprehensive, legible and complete.

Clinical Audit
Healthcall said it wanted to perform the audit of clinical records for several reasons:

It has an ongoing commitment to clinical governance
It wanted to examine clinical standards being provided by its service
It wanted to quantify the differences in standards of record-keeping, with a view to producing a protocol of record-keeping
It is committed to providing a top quality service to patients and to strive to continually develop and improve the service offered.

All of these points seemed to indicate that an audit of record-keeping was the way forward. While the company accepts that a poor record does not necessarily indicate a poor quality of eye examination, it has been shown that the two do go together on the whole. Although Healthcall is a domiciliary company, the audit principles that were used could be applied to any optometric practice.

Score sheet
A score sheet (Figure 1) was designed that contained a list of 25 points, which ensured that all details of the record card, and so the eye examination, were included. The score sheet was divided into five main sections:

Legibility and completeness of record
Completeness of clinical information
Patient consultation
Patient management plan
Patient referral.

It was decided to further divide these sections into sub-sections, since it was felt that some points were more important than others and also because we wanted to ensure that a high mark could not be attained by recording non-clinical information only. A percentage score was given for each section, as well as an overall final score.

Guidelines
A set of guidelines (Figure 2) was produced, ensuring that the marking of the records by the auditors was done in a strictly controlled, consistent and objective manner.

Process
The audit was conducted as follows:

All practitioners working for Healthcall at the time, both employed and locum were audited.
Practitioners had been informed well in advance that an audit was to take place but, naturally, no mention was made of the dates that were to be used in the audit. Subsequently two consecutive dates in July were chosen at random.
Copies of 20 record cards for each practitioner, from the chosen dates, were requested from the local branch office. If any practitioner had not worked on those days, the nearest dates to those selected were used.
The auditors, who were all members of Heathcall's professional Standards Committee, were allocated particular branches to audit; ensuring no one marked record cards from their own branch.
At the beginning of August 2003, the auditors were sent the copies of their allocated record cards, together with a set of guidelines and score sheet for each practitioner's set of records.
The score sheet listed the 25 points that were considered by the professional Standards Committee to be necessary inclusions on a good record. Each point was allocated either one mark for its presence or zero for its absence. In certain cases, such as Point 17 Ð Internal examination, it was recognised that half marks could be awarded, at the auditors' discretion, depending on the amount of clinical data recorded.
Each record card had a maximum of 25 marks available and each individual score was expressed as a percentage of those 25 marks.
The auditors were given one month to complete the task and in September 2003 the results were collated for analysis.

Results
The average percentage mark for the 20 record cards was calculated to be the final score for each practitioner. The average score for each practitioner was used to calculate a 'National Average', against which all the results were compared. The final results were expressed in terms of the position of each practitioner in relation to all the other practitioners in the country.
The individual practitioners' scores were used to give an overall 'branch average' score. The 'branch average' was used to express a league table of results for all the Healthcall branches in the country, eight in all. Every practitioner was informed of his or her results by post. They were also sent a blank copy of the score sheet and set of guidelines to indicate how the marking process was carried out.

Discussion
The audit results showed quite effectively the large spread of individual scores. It was expected that not all practitioners would score the same.
Many who did not achieve optimum scoring lost marks for what might be considered to be minor omissions, such as pupil reactions, previous Rx, patient advice etc. These are things which were probably actually done during the examination, but which have simply not been written down. Even simple things, such as neglecting to put their own name on the record, and whether the patient was given a change of prescription, were found and therefore marks were lost. Others may have written everything required, but not legibly.
The audit is to be an ongoing process, but the mechanics of it are to be slightly different in the future. Each individual practitioner will be audited at least once every year, but we do not intend to audit everyone at the same time routinely. Auditing the records of all the practitioners at the same time was a huge task. Therefore we intend to re-audit those whose scores were the lowest within the next three months. Those who scored highly in the original audit will be audited randomly throughout the year. Any new practitioners working for Healthcall will be audited within the first few weeks with the company.
It is not expected that all practitioners will achieve full marks Ð realistically this would not be possible. However, the company expects its practitioners to strive to achieve a score above the present national average in future audits, through constant peer assessment and support.
Recently, an interesting phenomenon has been noticed as a result of the audit process; those practitioners who have been asked to audit the records of others have all said that the process has improved their own record-keeping. In examining the records of other people, one is made more aware of one's own shortcomings in record-keeping, and so, improvements in one's own records are made. Additional data was gleaned from this audit that has proved particularly useful to the company, however, discussion of this data is outside the scope of this article.
Healthcall, as part of its CG commitment, intends to give full support to all its practitioners in trying to raise the standard of record-keeping, through continuing education, training and appraisals. This will become part of the practitioners' personal development plan. Ultimately, it is hoped that using the audit results as a guide a Healthcall record-keeping protocol will be developed.

Summary
In conclusion, it is necessary to produce good case records for several reasons. These include a document for own defence, should it ever be necessary; 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. The ideology that 'I have always done it this way so why do I need to change' can no longer exist. If the results of a procedure are not on the record card, then it is assumed that the procedure was not carried out. 'If you didn't write it, you didn't do it'.

Acknowledgements
Commission for Health Improvement. Members of Healthcall professional standards committee. Dr Bill Holmes, Nestor Group medical director.
Jayne Rawlinson, managing director Healthcall Optical Services. Special thanks to David Derrington, former professional services manager, Healthcall Optical Services.

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