association of optometrists litigation & record keeping presentation national optometric...

Association Association of Optometristsof Optometrists

LitigationLitigation&&

Record KeepingRecord Keeping

PresentationPresentationNational Optometric ConferenceNational Optometric Conference

by Fiona Mitchellby Fiona Mitchell

Head of Legal ServicesHead of Legal ServicesOctober 2006October 2006

Association Association of Optometristsof OptometristsLitigation and Record Litigation and Record

KeepingKeeping

Record keepingRecord keeping

Why do we keep records?Why do we keep records?- Patient benefitPatient benefit- Monitor trendsMonitor trends- DEFENCE OF OPTOMETRISTDEFENCE OF OPTOMETRIST

What records do we keep? What records do we keep?

EVERYTHINGEVERYTHING


KeepingKeeping

AttacksAttacks• Px complaintPx complaint

• GOCGOC

• SolicitorsSolicitors

• Health AuthorityHealth Authority

• OCCSOCCS

• Health OmbudsmanHealth Ombudsman


KeepingKeeping

• Current GOC TrendsCurrent GOC Trends

0

10

20

30

40

50

60

70

80

90

1998 2000 2002 2004 2006

No. cases

Association Association of Optometristsof OptometristsDefending the Defending the

OptometristOptometrist

Interrelation of ComplaintsInterrelation of ComplaintsPx ComplaintPx Complaint

Solicitors GOC OCCS PCO’sSolicitors GOC OCCS PCO’s

letterletter

Association Association of Optometristsof OptometristsDefending the Defending the

OptometristOptometrist PCO’s GOCPCO’s GOC

PCO Tribunal NHS (fraud) PCO Tribunal NHS (fraud) GOCGOC

LocalLocalresolution Crown Courtresolution Crown Court

HealthcareHealthcareCommissionCommission

FHSAA GOCFHSAA GOC


Litigation & Record Litigation & Record Keeping Keeping

What records do we keep?What records do we keep?Patient informationPatient information

ClinicalClinical

DispensingDispensing

Computerised or on paper?Computerised or on paper?Content remains the sameContent remains the same



Patient informationPatient informationOuter envelopeOuter envelope• Contact detailsContact details

– Address including postcodeAddress including postcode– Telephone number – daytime (work/home)Telephone number – daytime (work/home)– Other? – Mobile? e-mailOther? – Mobile? e-mail

• Optometrist identifierOptometrist identifier• Driving licenceDriving licence• Doctor’s name and addressDoctor’s name and address• Reminder -Reminder -

VITALVITAL



Clinical recordClinical recordPatient information (continued)Patient information (continued)

Family historyFamily history

Ocular historyOcular history

HealthHealth

MedicationMedication• HistoryHistory• SymptomsSymptoms

MAKE ENTRIES IN EVERY CASEMAKE ENTRIES IN EVERY CASE


Litigation & Record Litigation & Record KeepingKeeping

External - structuresExternal - structuresOcular motorOcular motorMotilityMotilityPupilsPupilsNPCNPC

InternalInternalMediaMediaVesselsVesselsDiscsDiscsMaculaMaculaPeripheryPeriphery

Clinical recordClinical recordExaminationExaminationObservations – right and leftObservations – right and left

NoteNote

nadnad



Clinical recordClinical recordExamination (continued)Examination (continued)Intra-ocular pressureIntra-ocular pressure• Time of measurementTime of measurement• Pressures in each eyePressures in each eye• Method of testMethod of test

Visual FieldsVisual Fields• Type of testType of test• FindingsFindings



Clinical recordClinical recordRefractionRefraction

Vision – unaidedVision – unaided

Record the prescription foundRecord the prescription found

Visual acuityVisual acuity

Record prescription issuedRecord prescription issued

NOTE ADVICE AND RECOMMENDATIONSNOTE ADVICE AND RECOMMENDATIONS



Clinical recordClinical recordContact lensesContact lenses• Initial Appointment/New patientInitial Appointment/New patient

– Separate CL record from spectacles recordSeparate CL record from spectacles record

– Note when patient last had a sight testNote when patient last had a sight test

– All appropriate information as for spectaclesAll appropriate information as for spectacles

• At the end of fitting:At the end of fitting:

- - Give the SpecficationGive the Specfication

- Written instruction on use and care of lenses- Written instruction on use and care of lenses



Clinical recordClinical recordContact lensesContact lenses• Continuing care appointmentsContinuing care appointments

– General history & symptoms since last visitGeneral history & symptoms since last visit

– wearing time – hours not days!wearing time – hours not days!

– Patient’s commentsPatient’s comments

– VA with CLsVA with CLs

– Over-refractionOver-refraction

– VAsVAs

– Detailed examination of anterior eye with & without CLsDetailed examination of anterior eye with & without CLs



Clinical recordClinical recordContact lensesContact lenses• Px compliancePx compliance• Conclusions & advice & actionsConclusions & advice & actions• Date of next appointmentDate of next appointment

Note if they do not attendNote if they do not attend

Association Association of Optometristsof OptometristsLitigation and Litigation and

Record keepingRecord keepingSupply of Contact lensesSupply of Contact lensesSupplier is now responsible for aftercare basic Supplier is now responsible for aftercare basic advice to be given to the patient on the following: advice to be given to the patient on the following:

• the need for routine continuing contact lens care the need for routine continuing contact lens care • contact numbers/addresses for emergency care.contact numbers/addresses for emergency care.

Aftercare is limited to this type of direction but Aftercare is limited to this type of direction but should be given to the patient in writing for theshould be given to the patient in writing for the protection of the supplier and NOTED on recordsprotection of the supplier and NOTED on records



Dispensing recordDispensing recordFrameFrameFacial measurementsFacial measurementsLensesLenses

Sign acknowledgement formSign acknowledgement form



Data Protection Act 1998Data Protection Act 1998Patient’s consentPatient’s consent• Taking recordsTaking records

• Keeping recordsKeeping records

• Passing records on to third partyPassing records on to third party

Consent at start of examinationConsent at start of examination

Note on recordNote on record– – need not be written consent (currently)need not be written consent (currently)

This is not the same as patient confidentialityThis is not the same as patient confidentiality

Association Association of Optometristsof OptometristsLitigation & Record Litigation & Record

KeepingKeeping

Access to medical recordsAccess to medical records

(Data Protection Act 1998)(Data Protection Act 1998)

Px’s are entitled to:Px’s are entitled to:• Explanation of original recordsExplanation of original records• Copies of Copies of allall the records the records



How long do we keep recordsHow long do we keep records

NHS terms of service 7 years NHS terms of service 7 years

Recommendation:Recommendation:

-Adults 10-12 years –dead or alive !-Adults 10-12 years –dead or alive !

-Children – until they reach the age of 25years-Children – until they reach the age of 25years

Limitation period –3yrs from the point of Limitation period –3yrs from the point of realisingrealising a a negligent act has occurrednegligent act has occurred



Who owns the records?Who owns the records?

BusinessBusiness

Optometrist needs access to recordsOptometrist needs access to records

Consider your position if you are a locum or employed Consider your position if you are a locum or employed and change jobsand change jobs


Record KeepingRecord KeepingRecord Keeping TipsRecord Keeping Tips• You should keep full records of the patient’s details, You should keep full records of the patient’s details,

clinical details and dispensing detailsclinical details and dispensing details

• The records should be clearly legibleThe records should be clearly legible

• The optometrist responsible for the examination The optometrist responsible for the examination should be identifiable from the record carshould be identifiable from the record car

• If you have not noted down the results of a test, it is If you have not noted down the results of a test, it is assumed you have not carried it outassumed you have not carried it out


Record KeepingRecord Keeping• It is no longer considered acceptable practice to use It is no longer considered acceptable practice to use

tick marks or the abbreviation ‘NAD’tick marks or the abbreviation ‘NAD’

• Note of all advice given to the patient and any Note of all advice given to the patient and any subsequent action, such as referralsubsequent action, such as referral

• Whether you record these details on paper or Whether you record these details on paper or electronically, the information should be the sameelectronically, the information should be the same

• When you leave the employment ensure you have When you leave the employment ensure you have access to the recordsaccess to the records



• There is a strong correlation There is a strong correlation between poor records and no defencebetween poor records and no defence

• We have 795 active casesWe have 795 active cases

• Litigation is here to stayLitigation is here to stay

• Best defence is a full recordBest defence is a full record



What to do in the event of a complaintWhat to do in the event of a complaint

CONTACT YOUR INSURERS IMMEDIATELYCONTACT YOUR INSURERS IMMEDIATELY

Most policies only respond if you have notified Most policies only respond if you have notified insurers of a potential claim insurers of a potential claim

DO NOT ADOPT THE OSTRICH APPROACHDO NOT ADOPT THE OSTRICH APPROACH


KeepingKeeping

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