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C-56606

Record keeping in contact lens practice

This article investigates what the ideal contact lens record could look like and whether practitioners have a consistent approach to record keeping.

Introduction

If you work regularly in contact lens practice you will probably recognise at least one of these scenarios. Scenario one: a patient attends for an aftercare appointment and says they are very happy with the new lenses they were given at the last visit, and consequently would like to change to them. Unfortunately, there is no record of what was issued at the last appointment which leaves you in the embarrassing situation of either trying to work out what the lenses were from the patient’s description of them or starting from scratch and trialling some new lenses. Neither option is ideal and both take up valuable chair time and make the practice look less than efficient.

Scenario two: on examination of the anterior eye you find a moderate amount of inferior ‘smile stain’ on the cornea. The record from the previous aftercare examination says, ‘cornea clear.’ Does that mean there was no staining and the staining you are seeing is caused by the lenses, or does it mean no fluorescein was used during the previous examination in which case you have no idea if the stain was there or not?

Unfortunately, both these scenarios are far too common, often due to time constraints in the consulting room.

The purpose of record keeping is ‘to retain clinical information, facilitate the management of the patient and continuity of care, to enable another practitioner to take over the care of a patient and protect yourself in case of complaints.’1 None of these objectives have been achieved in either of the above scenarios.

The aim of this article is to consider the legal obligations connected with contact lens record keeping, look at the guidance given by our professional bodies and the research evidence available for what could be considered best practice contact lens record keeping.

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General Optical Council Standards of Practice

There is surprisingly little guidance supplied by the optical professional bodies with specific regard to contact lens record keeping. The GOC Standards of Practice for Optometrists and Dispensing Opticians states that practitioners must ‘maintain clear, legible and contemporaneous patient records which are accessible for all those involved in the patient’s care’.2 Therefore, records must be easy to understand by another practitioner, written at the time of the examination or as soon as possible afterwards and available to all members of practice staff who may have dealings with that patient. This applies to both primary eye care and contact lens examinations and does not just cover the actual eye examination but also any other contact with the patient such as telephone conversations, contact lenses issued and advice given. The GOC standards also provide a minimum requirement covering the content of a patient record, and this list is shown in Figure 1 (Adapted from the GOC Standards of Practice for Optometrists and Dispensing Opticians recommendations for maintaining adequate patient records). This requirement covers all optometric record keeping; there is no specific requirement for contact lens records. 

Patient confidentiality and data protection 

All patient records, whether they are written or computer-based should be kept confidential. Records should be stored securely, and disposed of confidentially. The Data Protection Act 1998 says records should be kept no longer than necessary; 3 however, this is open to interpretation, and recommendations are for 10 years after the patient’s last visit to the practice for an adult or a patient who has deceased, and until the 25th birthday of a child.1,3

Individual practitioners also have responsibilities under the Data Protection Act 1998.4 The key points of the Act that relate to optometrists are listed in the College of Optometrists Guidance.1 The one with most relevance for day-to-day contact lens record keeping is the necessity to keep accurate patient data. The question is, during a contact lens examination, what is the best way to go about this?

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Clinical content of contact lens records

The College of Optometrists Guidance contains recommendations for the content of a primary care record card;1 however, there are no similar recommendations available for contact lens record keeping. The only comment made by the College is that if a contact lens examination is carried out along with the eye examination it is recommended the current lens specification and care regime should be recorded. If we break down the content of a contact lens examination, we can look at the evidence base for what is possibly best practice to record. It is reasonable to assume that a good contact lens record should include details of the initial discussion with the patient, the examination results (both positive and negative findings), a conclusion, and the advice given to the patient and action taken.5 We will look at each of these in more detail below.

History and symptoms

A thorough history and symptoms, whether for an initial contact lens fitting appointment, aftercare, or an unscheduled appointment, is critical to the decision-making process regarding the most suitable lens choice or best management options. Time is often limited in practice, therefore, questioning should be well structured to produce comprehensive and accurate records with the use of common, easily understood abbreviations.1 Using responses to a practitioner survey, recommendations as to the content of a contact lens history and symptoms have been produced by the British Universities Committee of Contact Lens Educators (BUCCLE).6 These recommendations are shown in Figure 2 (Recommendations for the content of history and symptom taking in contact lens fitting aftercare. Adapted from Wolffsohn et al5 *Not in the recommendations but are an integral part of a contact lens histroy and symptoms1)and will hold no surprises to most practitioners, although it is often useful to confirm that what you are doing as a practitioner is in line with colleagues. These are just recommendations though and questions will vary depending on the appointment. During a contact lens fit there may be detailed documentation of the patient’s general health, whereas in future aftercare appointments it would be enough to purely note any changes in health or medications. What is highlighted is the importance of recording the differential diagnosis of symptoms such as pain or red eye, as this indicates which further examinations need to be carried out and adds weight to the course of action for that patient, particularly when differentiating between microbial keratitis and a sterile infiltrate.

Clinical examination

The clinical examination covers a number of aspects: visual acuity with the lenses, including over refraction and visual stability; an assessment of the fit of the contact lenses, including inspection of the lens surface; and examination of the anterior eye without the lenses, including tear film assessment and keratometry readings.

The fit of a lens is seen recorded in various ways on a contact lens record. There may be a comment of ‘fit good’ or ‘fit 4’ neither of which is particularly useful for future reference. The lens centration, horizontal lag, post blink movement and push up recovery speed are the measurements that best predict the fit of a soft contact lens,7,8 and as such should be documented. The traditional method of doing this can be seen in Figure 3a (Diagrammatic method of recording a good fitting soft contact lens: (a) a traditional diagram; (b) a simplified method of recording lens fit)9 where the lag and post blink movement have been documented in millimetres and the speed of recovery of the push up test has been commented on. A simplified version of this recording has been recommended by Wolffsohn et al where +/0/- are used to indicate the amount of movement and speed of push up recovery (see Figure 3b).9 Both these recording methods are quick and simple to use and give far more information than the comment of ‘good fit’.

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Recording of the slit lamp examination is the method by which we as practitioners can monitor any changes occurring due to contact lens wear. A search of the professional optometric websites found no recommendations on what exactly should be recorded when an anterior eye examination is carried out. The AOP recommends that the use of ‘tick marks’ or NAD are not clinically acceptable as they do not provide enough information unless the record is very specific about what it relates to. For instance, ‘meibomian glands – NAD’ may be acceptable as it is quite specific about what has been examined, whereas ‘anterior eye – NAD’ would not be specific enough.10 A better way of documenting the health of the anterior eye is possibly to use a grading scale such as the Efron or Brian Holden Institute grading scales among others.11 The Efron scales are a series of stylised drawings of a number of anterior eye conditions each of which has five levels of severity. The Brian Holden Vision Institute scales contain real photographs of conditions with four levels of severity. These are widely available from contact lens manufacturers, in apps and on the internet. Advice to practitioners is that a change of one unit in either of these scales is clinically significant, although practitioners are advised to record to 0.1 of a unit to help precision.12 The scales are not interchangeable, and it is recommended to consistently use the same scale.This is particularly advisable in large practices where a patient may be seen by one of several clinicians, as it would help to standardise recording of the anterior eye examination and enhance continuity.11

How widely are grading scales used in practice? An Australian study found that just over 60% of optometric practitioners used grading scales to some extent, although the majority of these practitioners only used the scales for recording complications.13 In a larger worldwide study, 85% of practitioners reported using grading scales, mainly the Efron or Brian Holden Vision Institute scales, with no apparent preference for either.12 Among Australian optometric practitioners, those using grading scales were more likely to be recently qualified, have postgraduate therapeutics qualifications and see more contact lens patients per week than those who didn’t. Surprisingly, only just over 50% of these practitioners referred to a hard copy when assessing a condition, presumably the remainder graded from memory.

Corneal staining was the complication most frequently graded, followed by contact lens induced papillary conjunctivitis and conjunctival injection. That most practitioners tend to only use grading scales to record complications suggests a tendency to only recording positive findings. College guidance is to record negative findings as well as positive,1 as the absence of recording is interpreted as a failure to undertake the test. BUCCLE recommendation is to grade the following at every visit whether it is felt to be normal or abnormal: bulbar and limbal hyperaemia; limbal neovascularisation; papillary conjunctival redness and roughness; blepharitis, meibomian gland dysfunction; and corneal staining with fluorescein.12 The advice is: to document the grading scale used as different scales are not comparable; to use a visible grading scale rather than trying to grade from memory; and to grade to 0.1 decimal place.

Figure 4 (Illustration of an eye: (a) prior to contact lens fitting; (b) after six months contact lens wear. Image courtesy of Dr Samantha Strong) illustrates the right eye of a patient before and after six months of contact lens wear. The difference between the two eyes is subtle, and either eye could be classed as ‘normal.‘ However, when the two eyes are directly compared there is a visible difference in conjunctival hyperaemia. If the original fitting record recorded the conjunctiva as ‘clear’ or ‘normal’ this change would certainly not have been detected, but if the original record had recorded conjunctival hyperaemia grade 0 (Efron) the change may have been picked up.

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Advice given

Anecdotally, this is the area of contact lens record keeping that is often carried out least effectively. Many complaints made by patients in optometric practice could be avoided by improved communication; however, not only do we need to explain our actions to our patient, we also need to document what we have said.

In line with College Guidance any advice regarding compliance, handling of lenses, wearing times and solutions should be documented and information leaflets issued.1 Changes in lens type, prescription or wearing schedule should be documented and the reason for this explained clearly to the patient, particularly in relation to any problems the patient has mentioned during the initial discussion. Differential diagnosis of sore or red eyes should be backed up by clear records of anterior eye examination and the thought process behind the management plan. The next planned appointment should always be recorded, and should a patient not attend for an aftercare it is important this is detailed on the patient record.

Conclusion

The purpose of patient records is to facilitate patient care and continuity between practitioners, and to protect the practitioner should a complaint arise. As we have seen, there is little guidance available as to what should be documented on a contact lens record, and sometimes patient records are not as detailed as they possibly should be. As an individual practitioner, it is good practice to randomly review your contact lens records to assess how easy they are to follow and if, in hindsight, any information is missing. It is a brave practitioner who puts their records up for scrutiny by colleagues; however, especially in large practices, auditing each other’s records and discussing the results can only lead to a higher standard of record keeping and improved continuity between eye care practitioners. 

About the author

Dr Alison Alderson PhD, MCOptom graduated with a degree in Ophthalmic Optics from UMIST in 1990 and gained registration with the GOC in 1991. After working in both private and hospital practice she returned to study and gained a PhD from the University of Bradford in 2011, during which time she supervised undergraduate clinics, worked as a locum optometrist in private practice and as a hospital optometrist. Her current position is as a staff optometrist at the University of Bradford, where she is responsible for teaching the undergraduate contact lens module. 

References 

  1. College of Optometrists (2017). Accessed 11 March 2017
  2. GOC Standards of Practice for Optometrists and Dispensing Opticians (2016). Accessed 11 March 2017
  3. Association of Optometrists (2017) Common legal questions. Accessed 11 March 2017
  4. Data Protection Act (1998)
  5. Warburton T (2004) Litigation and record keeping: better to be safe than sorry. Optometry Today August 20: 20-23
  6. Wolffsohn JS, Naroo SA, Christie C et al. (2015) History and symptom taking in contact lens fitting and aftercare. Contact Lens & Anterior Eye 38: 258-265.
  7. Young G (1996) Evaluation of soft contact lens fitting characteristics. Optometry & Vision Science 73(4): 247-254.
  8. Boychev N, Laughton DS, Bharwani G et al. (2015) How should initial fit inform soft contact lens prescribing. Contact Lens & Anterior Eye 39(3):227-233.
  9. Wolffsohn JS, Hunt OA, Basra AK (2009) Simplified recording of soft contact lens fit. Contact Lens & Anterior Eye 32: 37-42. 
  10. Association of Optometrists (2015) Staying out of trouble. Accessed 11 March 2017
  11. Efron N, Morgan PB, Katsara SS (2001) Validation of grading scales for contact lens complications. Ophthalmic & Physiological Optics 21(1): 17-29
  12. Wolffsohn JS, Naroo SA, Christie C et al. (2015) Anterior eye health recording. Contact Lens & Anterior Eye 38: 266-271
  13. Efron N, Pritchard N, Brandon K et al. (2011) A survey of the use of grading scales for contact lens complications in optometric practice. Clinical & Experimental Optometry 94(2): 193-199.