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The standard of clinical record keeping is extremely variable. It is easy to get stuck into poor habits of record keeping. Accurate record keeping is important for the provision of quality eyecare, especially in a multi-practitioner setting, to protect the optometrist in the event of an accusation of negligence and for use in My Health Record to be accessed by other practitioners. Not surprisingly, there is a strong link between poor record keeping and successful claims against practitioners for clinical negligence.
Optometrists tend to under-report, that is, perform and examine more than is recorded on their record cards.
The Optometry Board of Australia Guidelines dictate that optometrists must: "Keep accurate, up-to-date and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be interpreted by another optometrist."
Here are some reminders and tips to refresh your clinical record keeping skills:
- Detail your case history: This should have a clear indication of the patient's concerns and complaints that led them to seek a consultation. Questions asked during history taking (negative or positive answers aside) must be recorded. Their ocular and health history, medications and allergies and adverse reactions must also be recorded.
- Examination findings: The results of every test and procedure performed should be recorded, whether it is normal or negative. It should be recorded in a way that it is easy to interpret. Recording such as WNL (within normal limits) or NAD (no abnormality detected) should be preceded by the tissue or structure examined. e.g. Cornea WNL.
- Therapeutic prescriptions: When a therapeutic medication is prescribed, supplied or administered by the optometrist (including diagnostic eyedrops), the date and details of the medication should be recorded alongside the instructions given to the patient.
- Be smart with your smartphone: Increasingly, clinical images may be captured on private hand-held smartphones. A good example is taking an anterior eye photo with a phone camera through a slit-lamp. Clinical images and videos on your mobile device are considered part of the patient's clinical record, and should be treated as such. Patient consent is essential when capturing images or videos using your smartphone or tablet. Patients when giving consent should understand the purposes of the clinical image, how the image will be used, who will have access to the image, whether it will be de-identified, and how the image will be stored. Once consent is obtained, document this on the patient’s clinical file and delete the file from your device after the image has been transferred to your computer