My clinician’s notebook

By the same token of providing the best clinical care, there is a need to keep our knowledge up-to-date with the latest medical and technological advances.

Early on in my career as an optometrist, I can recall the case of a colleague who had referred a patient routinely to secondary care via the general practitioner for further investigation. To the disappointment of the optometrist, the referral request was never acted upon by the general practitioner. In this case, the patient unfortunately assumed that a hospital appointment would eventually come through the letterbox while their vision continued to deteriorate.

After learning about this case, I remember asking my colleagues what they would have done differently, and amongst the suggestions was one that has stayed with me to this day – the clinician’s notebook. Here I share three reasons why I could not live without my clinician’s notebook.

Highest standards of patient care

Nowadays, when I make a referral I seek permission from my patients to keep a note of their contact details and the referable condition in my clinician’s notebook. At a later agreed date, I make contact with the patient by phone to ensure that they have been referred appropriately. During the phone call with the patient, any information relayed or gained is duly noted in their record card. The benefit of this approach is twofold: ensuring my duty of care to the patient, while I continue to gain vast amounts of knowledge about secondary care from my patients.

From the patient’s perspective, they are generally impressed by the personal care and attention given to them.

"Given its worth, my black hardback Moleskine notebook is always safely stored away in a drawer, an arm’s length from my consulting chair"

Follow up appointments

It is not unusual for a patient to request to return for a dilated funduscopy or cycloplegic refraction on a different day. Often simply because the patient is short of time that day or because they have driven to attend the appointment, which is a contraindication for these types of investigative drugs. If it is not this scenario, then it may be a red eye that needs to be followed up to ensure the patient has made a full recovery based on the treatment plan recommended by the optometrist.

In all these scenarios, the optometrist can go that extra mile to ensure the patient is compliant with the advice given. Recording in my clinician’s notebook when I expect the patient to return is a useful personal tool that enables me to cross check that the patient does attend the requested follow up. If not, anyone from the practice can be prompted to contact the patient to help them reschedule the missed appointment.

Continuing professional development

For those of us who qualified more than three years ago, we are acutely aware that new drugs and advancing technologies enter the market every month. When a patient lists a drug, health condition or treatment that I have not come across in the past, or do not clearly understand, my clinician’s notebook springs out into action. This will be regularly true for newly-qualified colleagues too. Rather than random scraps of paper in the test room, it is useful to have a dedicated place to record our desired learning goals.

Given its worth, my black hardback Moleskine notebook is always safely stored away in a drawer, an arm’s length from my consulting chair. Considering the patient sensitive data that is contained within, my clinician’s notebook does not travel with me like a personal diary.

While its simplistic nature and modest appearance may not be comparable against the ever growing, sleek, technological advances in the optometrist’s test room – perhaps its merit is best summed up metaphorically:“don’t judge a book by its cover.”

Image credit: Getty