For the record
Head of clinical and regulatory at the AOP, Henry Leonard, shares his advice on the importance of keeping clear and accurate clinical records as a locum
14 April 2023
Record keeping is a key aspect of any practitioner’s practice. Clinical records not only describe the care that took place but ensure that future care is fully informed.
For locum optometrists, who move between practices, being conscientious about completing a full and accurate patient record is paramount.
Long after a locum has left a practice, their clinical records remain as a professional legacy of the care they provided.
“Clinical records should provide full details of an episode of care,” he shared.
“Good records not only ensure that patients receive proper continuity of care, but also serve as evidence of what took place should a complaint arise,” Leonard observed.
He added that if a particular test is not recorded, then there is likely to be an assumption by the optical regulator that it was not carried out.
Over time expectations regarding the amount of information that needs to be recorded have increased, Leonard shared, meaning that older practitioners can be particularly vulnerable to allegations of sub-standard record keeping.
Clinical records should provide full details of an episode of care
Leonard recommends taking a moment at the end of the examination to review the patient’s clinical notes and ensure that they provide a clear narrative of the care provided.
“In FtP cases, practitioners are often criticised for not properly addressing the patient’s presenting symptoms, so it’s important to check that the advice recorded fully addresses the symptoms you recorded at the beginning of the examination,” he said.
Optometry practices use a variety of different systems for patient records, and many are fully or partly digital.
“When working as a locum, it’s a good idea to ask which system the practice uses in advance of your clinic, and if you haven’t used it before, ask for some time to be set aside before your first patient, so you can become familiar with it,” Leonard advised.
He added that many practices now perform record keeping audits to ensure that practitioners are recording the necessary information consistently.
These processes can be helpful in identifying areas of record keeping that may have been overlooked in the past.
“Asking a colleague for comments on your record-keeping can also highlight issues which you may not have even considered, such as the use of abbreviations or legibility,” Leonard shared.
If you are unsure about how to manage a scenario in practice, please contact [email protected]
Five record keeping tips
Henry’s guidance on providing a full record of patient care.
- Check that the advice recorded at the end of the examination fully addresses the patient’s presenting symptoms
- Clearly record any ‘safety-netting’ advice you have given (Eg “patient advised to contact the practice in two weeks’ if not heard from hospital clinic regarding urgent referral”)
- If the patient has received a supplementary test such as retinal imaging or visual fields, record that you have reviewed this information within the clinical notes, along with any relevant comments about the results
- If the practice performs regular record-keeping audits, use this as a way of identifying areas for improvement, or ask a colleague for their comments
- Keep up to date with current guidance on what should be recorded.
The AOP Locum Logbook
An online tool to support thorough record keeping
Supported by Johnson & Johnson Vision, the AOP Locum Logbook has been developed to help locum AOP members keep a record of the work they are responsible for.
The tool is separated into four sections: practice details, internal referrals and investigation requests, local area protocols, and useful resources.
The online version of the logbook was developed in response to member feedback, following on from the initial hardcopy AOP Locum Logbook that was distributed between 2019 and 2020.