Seven record keeping tips

Independent prescribing optometrist, Farah Topia, is a clinical advisor at the AOP.

A large part of her role involveslooking at clinical records, interpreting them, understanding what a practitioner has done, how they might have reached a clinical decision, and understanding what the patient management was.

Day-to-day Topia sees how effective record keeping can protect practitioners in the event of a complaint or investigation.

“It’s really important that you, and other optometrists who might see the patient in the future, can look at your records and understand quickly what has taken place,” she emphasised.

In Topia’s experience, if a clinical record clearly indicates a practitioner’s findings, their management and the advice the patient was given, there is a good chance that the complaint will not escalate.

Here’s Topia shares seven tips to support optometrists to practise safely.

1 Record the patient’s reason for the visit

Farah says: “It’s important to check that the advice you record, and the advice that you give to the patient at the end of the examination, fully addresses the patient’s presenting symptoms. Using the patient’s own words, and referring back to that when you’re summarising, shows that you’ve fully considered the patient’s reason for visit.”

2 Record your ‘safety-netting’ advice

Farah says: “It’s important to clearly record any safety-netting advice that you give.If there’s anything on there encouraging the patient to follow up if they haven’t heard following a referral, documenting that and giving that advice to the patient will offer you some protection in the event a referral is delayed.”

3 Supplementary tests

Farah says:“If the patient has had another test done, such as retinal imaging or visual fields, make sure that you review this information because it does form part of the clinical records, even if you haven’t seen it. Making a note that the test was done, that you’ve reviewed the records, and also noting anything you’ve noticed about them – if you did see a disc haemorrhage, make a note, write disc haemorrhage – it helps the future care of the patient, and it shows that you haven’t overlooked it.”

Falsifying a record, which shows dishonesty, can be really difficult for a professional in a healthcare role and a position of trust to recover from

4 Record keeping audit

Farah says: “If your practice performs regular record keeping audits, use it to help identify areas for improvement. It’s really helpful to take a moment to reflect and look at your records in a more critical manner.”

5 Keep up-to-date with current clinical and regulatory guidance

Farah says: “Keep up-to-date with current clinical guidance. It’s really easy to get stuck in a rut doing what you’ve done. Regular CPD and regular reviewing of the current guidance is really helpful to make sure you’re practising to your best ability.”

6 Time considerations: speak up

Farah says: “All these things that we’re asking you to do, record this and record that – it all takes time. If that’s an issue, speak to your line manager. If you need to raise a formal concern, you can do that in writing. You can contact the AOP and we can advise.”

7 Never falsify records

Farah says: “Never falsify records. Missing pathology is forgivable, it can happen to the best of us. But falsifying a record, which shows dishonesty, can be really difficult for a professional in a healthcare role and a position of trust to recover from. It’s okay to make a mistake, but we never go back and falsify records.”