On stage at 100% Optical: master record keeping

In the lead-up to 100% Optical 2023 in February, OT reached out to a selection of speakers from the education programme to find out more about the sessions on offer, the topics that will be explored, and what visitors can expect. Find the full series, along with further content on 100% Optical on OT’s dedicated page.

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What is the focus of your session?

Cassandra Dighton (CD), AOP head of professional discipline: We hope to give delegates a refresher on record keeping. We’re going to be sharing some cautionary tales from our practise, as well as some top tips and a refresher on the importance of records.

Henry Leonard (HL), AOP head of clinical and regulatory: It is one of those topics that comes up all the time in investigations. Often in NHS investigations, even if they don’t start off as a record keeping concern, the NHS will identify issues with the clinical notes which need to be addressed.

What are some of the key messages you wish to highlight?

CD: Having a decent record creates a potential avenue of defence should your case ever be referred to the General Optical Council (GOC).

HL: One of the messages I try to get across in record-keeping presentations is that I think optometrists don’t always realise how good records can help protect them if there was a complaint.

Often in a case that goes to the GOC, the patient will be saying one thing, and the practitioner will say something different. If the clinical records support the optometrist’s version of events, the AOP and the member are in a stronger position to build a defence that the optometrist version of events is the correct one.

Who is this topic for? Who might benefit the most from joining?

HL: I think it is particularly beneficial for older practitioners, because it can be easy to get out of touch with record keeping, and what was acceptable 20 years ago is no longer acceptable. We see it time and again in NHS investigations where record keeping isn’t up to modern standards.

CD: It is particularly important if you’re not using a computerised system.

This session is also valuable for pre-regs as a reminder of why you need to make those important records. But it’s useful for everyone, because every optometrist should be making records. It is a bit like driving – it can be easy to develop bad habits once you’ve passed the driving test.

What do you hope the top takeaway will be for attendees?

HL: My bugbear is when records don’t make sense. Patients will come in with certain symptoms and it is really important that the symptoms at the top of the record are addressed by the advice given at the bottom of the record. I will always say to practitioners: take a moment at the end of the examination to look back at the presenting symptoms. Have you addressed them at the end, does it make sense? So many of the complaints we see are because the advice given doesn’t really match what the patient came in with.

CD: The ability to make good records is a key skill which is often neglected. I want every attendee to take a moment to reflect on their own habits and ask themselves whether they need to improve their notes – the reality is, that the record could be crucial in future.