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Association of Optometrists Litigation & Record Keeping Presentation National Optometric Conference by Fiona Mitchell Head of Legal Services October 2006 Litigation and Record Keeping Record keeping Why do we keep records? - Patient benefit - Monitor trends - DEFENCE OF OPTOMETRIST What records do we keep? EVERYTHING Association of Optometrists Litigation and Record Keeping Attacks • • • • • • Px complaint GOC Solicitors Health Authority OCCS Health Ombudsman Association of Optometrists Litigation and Record Keeping Association of Optometrists • Current GOC Trends 90 80 70 No. cases 60 50 40 30 20 10 0 1998 2000 2002 2004 2006 Defending the Optometrist Association of Optometrists Interrelation of Complaints Px Complaint Solicitors letter GOC OCCS PCO’s Defending the Optometrist PCO’s PCO Tribunal Local resolution Association of Optometrists GOC NHS (fraud) GOC Crown Court Healthcare Commission FHSAA GOC Litigation & Record Keeping What records do we keep? Patient information Clinical Dispensing Computerised or on paper? Content remains the same Association of Optometrists Litigation & Record Keeping Association of Optometrists Patient information Outer envelope • Contact details – Address including postcode – Telephone number – daytime (work/home) – Other? – Mobile? e-mail • • • • Optometrist identifier Driving licence Doctor’s name and address Reminder VITAL Litigation & Record Keeping Association of Optometrists Clinical record Patient information (continued) Family history Ocular history Health Medication • History • Symptoms MAKE ENTRIES IN EVERY CASE Litigation & Record Keeping Association of Optometrists Clinical record Examination Observations – right and left Internal Media Vessels Discs Macula Periphery External - structures Ocular motor Motility Pupils NPC Note nad Litigation & Record Keeping Clinical record Examination (continued) Intra-ocular pressure • Time of measurement • Pressures in each eye • Method of test Visual Fields • Type of test • Findings Association of Optometrists Litigation & Record Keeping Association of Optometrists Litigation & Record Keeping Association of Optometrists Clinical record Refraction Vision – unaided Record the prescription found Visual acuity Record prescription issued NOTE ADVICE AND RECOMMENDATIONS Litigation & Record Keeping Association of Optometrists Clinical record Contact lenses • Initial Appointment/New patient – Separate CL record from spectacles record – Note when patient last had a sight test – All appropriate information as for spectacles • At the end of fitting: - Give the Specfication - Written instruction on use and care of lenses Litigation & Record Keeping Association of Optometrists Clinical record Contact lenses • Continuing care appointments – – – – – – – General history & symptoms since last visit wearing time – hours not days! Patient’s comments VA with CLs Over-refraction VAs Detailed examination of anterior eye with & without CLs Litigation & Record Keeping Association of Optometrists Clinical record Contact lenses • Px compliance • Conclusions & advice & actions • Date of next appointment Note if they do not attend Litigation and Record keeping Association of Optometrists Supply of Contact lenses Supplier is now responsible for aftercare basic advice to be given to the patient on the following: • the need for routine continuing contact lens care • contact numbers/addresses for emergency care. Aftercare is limited to this type of direction but should be given to the patient in writing for the protection of the supplier and NOTED on records Litigation & Record Keeping Dispensing record Frame Facial measurements Lenses Sign acknowledgement form Association of Optometrists Litigation and Record Keeping Association of Optometrists Litigation & Record Keeping Association of Optometrists Data Protection Act 1998 Patient’s consent • Taking records • Keeping records • Passing records on to third party Consent at start of examination Note on record – need not be written consent (currently) This is not the same as patient confidentiality Litigation & Record Keeping Access to medical records (Data Protection Act 1998) Px’s are entitled to: • Explanation of original records • Copies of all the records Association of Optometrists Litigation & Record Keeping Association of Optometrists How long do we keep records NHS terms of service 7 years Recommendation: -Adults 10-12 years –dead or alive ! -Children – until they reach the age of 25years Limitation period –3yrs from the point of realising a negligent act has occurred Litigation & Record Keeping Association of Optometrists Who owns the records? Business Optometrist needs access to records Consider your position if you are a locum or employed and change jobs Litigation and Record Keeping Association of Optometrists Litigation and Record Keeping Association of Optometrists Record Keeping Tips • You should keep full records of the patient’s details, clinical details and dispensing details • The records should be clearly legible • The optometrist responsible for the examination should be identifiable from the record car • If you have not noted down the results of a test, it is assumed you have not carried it out Litigation and Record Keeping Association of Optometrists • It is no longer considered acceptable practice to use tick marks or the abbreviation ‘NAD’ • Note of all advice given to the patient and any subsequent action, such as referral • Whether you record these details on paper or electronically, the information should be the same • When you leave the employment ensure you have access to the records Litigation and Record Keeping Association of Optometrists • There is a strong correlation between poor records and no defence • We have 795 active cases • Litigation is here to stay • Best defence is a full record Litigation & Record Keeping Association of Optometrists What to do in the event of a complaint CONTACT YOUR INSURERS IMMEDIATELY Most policies only respond if you have notified insurers of a potential claim DO NOT ADOPT THE OSTRICH APPROACH Litigation and Record Keeping Association of Optometrists