For the record

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.

Head of clinical and regulatory at the AOP, Henry Leonard, shared with OT that allegations of poor record keeping are a common feature of fitness to practise (FTP) cases investigated by the General Optical Council.

“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]