View from the High Street: Let the record show
Judy Lea enthuses about the value of keeping thorough and accurate notes
Author: Judy Lea
In practice we have always performed regular audits on professional records and we are in the midst of one now. As we have become larger and employed more optometrists, I see this as a useful health check on the business and to highlight any personal development needed.
The audit involves sampling records from recent months and ensuring that adequate notes have been recorded, along with full refraction results and more importantly eye health examination notes and advice given to the patient. It also looks at the recall that was selected for each patient.
A rule I have made over the years is that even if the patient falls into a category where we could see them sooner than the standard 24 months, any recall less than 24 months should have notes to say why. This makes it easier for the optometrist who examines the patient at a subsequent visit and for support colleagues who may be asked by patients why they may have a different recall than, say, their husband or wife.
Patients’ attitudes to attending examinations seems to be changing. We find that for most, the more frequent the recall, the less compliant they are at attending, particularly if they have no symptoms. They lead increasingly busy lives and almost appreciate it more if we don’t recall them frequently (unless there is a clinical need that is explained well to them). Some, on frequent recalls, have almost seen it as a money-making exercise to sell them a further pair of spectacles, regardless of us having explained the
When the idea of auditing professional records was first introduced to me, I couldn’t see why we would need to look at each others’ records and I was concerned at how it would be received by colleagues. However, receiving no feedback can often be just as badly perceived, and I use it to highlight areas of good practice as well as areas where we may need to look at improving procedures.
The pre-registration optometrists’ records are always of a very high standard and I hope that they will continue to be so throughout their careers. Re-visiting our record keeping every so often will remind us all of the importance. Like driving a car, after many years we all fall into bad habits, and while I am quite sure that I would fail my driving test were I to take it again tomorrow, I hope that wouldn’t be the case with record keeping due to this constant review.
I feel that I have nothing to hide from the point of view of my records and even from the way I conduct an eye examination and would always welcome any pointers or shadowing to improve, as would most conscientious fellow professionals. Optometrists who have worked with me over the years will no doubt know my pet hates when it comes to record keeping. One is where they hit the tab under reason for visit as ‘routine’. When they then find a change to the prescription, how can they justify prescribing it to a patient with no symptoms?
When I qualified, we were constantly told how important it was to write copious notes and even record any tests that you were unable to perform with the reasons why. One lecturer would repeat that if it isn’t written down you haven’t done it and say that good records should read like a story that all makes sense at the end, with the advice given tying up with the reason the patient presented or the recorded acuities in their existing spectacles. As society has become more litigious, this mantra has never been more significant. However, we were also taught all the acronyms to use on records to describe the ‘more challenging’ individuals that we come across… that would most certainly be discouraged and frowned upon nowadays.
The value of good record keeping was evidenced a few years ago when a young contact lens patient was unhappy that a rare pathological eye condition had not been detected as part of her routine aftercare appointments. However, the records were well written, there were never any symptoms presented and all relevant clinical tests and findings were well documented. In addition, we had diligently recorded the follow-up appointments which she had failed to attend. I was extremely grateful for good record keeping in that instance.
Shortly we will be lucky enough to have access to a new clinical outcome report which will enable us to see in even more detail our average recalls in the various age bands and referral patterns alongside a host of other data which should help to identify any unusual patterns. In this way – as well as highlighting personal development needs – we can ensure that spending on eye care and referrals for the NHS is done in the most appropriate way which should hopefully result in both happier patients and happier NHS commissioners.
Judy Lea is optometrist director of Specsavers, Longton, Staffordshire.