Noteworthy: how thorough record keeping can improve patient care

A rounded view of thorough record keeping was presented as part of Christopher Bagot’s 100% Optical session, Beyond compliance – the comprehensive benefits of good record keeping.

The optometrist highlighted that maintaining clear and comprehensive records ease the load on both the optometrist and practice team, as well as locum optometrists who work in a practice.

“No one’s records are perfect, but what you have to do is the best you can with the information you have available to you,” Bagot said.

He shared it is important to take note of the information the patient provides before they enter the testing room.

“The journey through the practice doesn’t start when they sit in the chair, but in their first contact with the practice,” Bagot observed.

While for some patients this might be a recall letter for a routine appointment, the growth of extended services in optometry practices means that the patient may be calling with a more urgent eye problem.

Bagot highlighted the value of finding out any symptoms the patient might be experiencing early in the patient journey.

“I always encourage my staff to ask, ‘are you having any problems?’,” he shared.

He explained that this avoids the potential for a patient to withhold information that could be important. Bagot shared the example of a woman with temporal arteritis who only mentioned that the side of her head was sore and she was having problems eating at the end of the sight test.

A good patient record should explain what the patient came in reporting, what actions a practitioner took, and why they took these actions.

Bagot shared that imaging technology has become an integral part of the record keeping process.

He added that while he generally charges for imaging, he will provide free imaging in some circumstances – for example, if it will help him run to time or save him from using less effective techniques to work out what is going on.

Bagot will also provide free imaging in order to ease the potential stress of wondering if he has made the right decision when he gets home.

Using discretion when it comes to performing imaging on patients can also lead Bagot to be more confident in his referrals to secondary care.

“You don’t want a reputation with the hospital for sending in guesswork,” he said.

Bagot outlined how feedback on the care provided in practice can take many forms – including letters back from hospital, patients returning to practice with issues or patients returning to practice for their next routine appointment.

“Feedback is something that you get by default,” he shared.

“If people like you, they recommend you. You get repeat business and your business grows,” Bagot highlighted.

Turning to the use of acronyms in records, Bagot reflected that while abbreviations can be convenient – especially within a single practice with the same staff – shortening phrases can create confusion for locums working in practice, or in records provided to secondary care.

For example, Bagot shared that OD may be understood as the right eye in optometric practice, but could be confused with an overdose in a secondary care setting.

Similarly, many optometrists would consider SLT to stand for selective laser trabeculoplasty, but in an NHS setting the acronym may be interpreted as speech language therapist.

He referred to UK research published in 2023 that involved 15 nurses, 15 trainee doctors and 16 consultants completing a questionnaire on the meaning of 20 common abbreviations used in healthcare.

The mean number of acronyms correctly identified was 6.39 out of 20.

“There is potential for confusion,” Bagot said.

“Acronyms are really handy but I am showing why caution may be a good idea,” he added.