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Association of Optometrists Litigation & Record Keeping Presentation National Optometric Conference by Fiona Mitchell Head of Legal Services October 2006.

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Presentation on theme: "Association of Optometrists Litigation & Record Keeping Presentation National Optometric Conference by Fiona Mitchell Head of Legal Services October 2006."— Presentation transcript:

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2 Association of Optometrists Litigation & Record Keeping Presentation National Optometric Conference by Fiona Mitchell Head of Legal Services October 2006

3 Association of Optometrists Litigation and Record Keeping Record keeping Why do we keep records? -Patient benefit -Monitor trends -DEFENCE OF OPTOMETRIST What records do we keep? EVERYTHING

4 Association of Optometrists Litigation and Record Keeping Attacks Px complaintPx complaint GOCGOC SolicitorsSolicitors Health AuthorityHealth Authority OCCSOCCS Health OmbudsmanHealth Ombudsman

5 Association of Optometrists Litigation and Record Keeping Current GOC TrendsCurrent GOC Trends

6 Association of Optometrists Defending the Optometrist Interrelation of Complaints Px Complaint Solicitors GOC OCCS PCO’s letter letter

7 Association of Optometrists Defending the Optometrist PCO’s GOC PCO’s GOC PCO Tribunal NHS (fraud) GOC PCO Tribunal NHS (fraud) GOC Local Local resolution Crown Court Healthcare Commission FHSAA GOC FHSAA GOC

8 Association of Optometrists Litigation & Record Keeping What records do we keep? Patient information ClinicalDispensing Computerised or on paper? Content remains the same

9 Association of Optometrists Litigation & Record Keeping Patient information Outer envelope Contact detailsContact details –Address including postcode –Telephone number – daytime (work/home) –Other? – Mobile? Optometrist identifierOptometrist identifier Driving licenceDriving licence Doctor’s name and addressDoctor’s name and address Reminder -Reminder - VITAL

10 Association of Optometrists Litigation & Record Keeping Clinical record Patient information (continued) Family history Ocular history HealthMedication HistoryHistory SymptomsSymptoms MAKE ENTRIES IN EVERY CASE

11 Association of Optometrists Litigation & Record Keeping External - structures Ocular motor MotilityPupilsNPC InternalMediaVesselsDiscsMaculaPeriphery Clinical record Examination Observations – right and left Note  nad 

12 Association of Optometrists Litigation & Record Keeping Clinical record Examination (continued) Intra-ocular pressure Time of measurementTime of measurement Pressures in each eyePressures in each eye Method of testMethod of test Visual Fields Type of testType of test FindingsFindings

13 Association of Optometrists Litigation & Record Keeping

14 Association of Optometrists Litigation & Record Keeping Clinical record Refraction Vision – unaided Record the prescription found Visual acuity Record prescription issued NOTE ADVICE AND RECOMMENDATIONS

15 Association of Optometrists Litigation & Record Keeping Clinical record Contact lenses Initial Appointment/New patientInitial 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:At the end of fitting: - Give the Specfication - Written instruction on use and care of lenses

16 Association of Optometrists Litigation & Record Keeping Clinical record Contact lenses Continuing care appointmentsContinuing 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

17 Association of Optometrists Litigation & Record Keeping Clinical record Contact lenses Px compliancePx compliance Conclusions & advice & actionsConclusions & advice & actions Date of next appointmentDate of next appointment Note if they do not attend

18 Association of Optometrists Litigation and Record keeping 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 carethe 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 should be given to the patient in writing for the protection of the supplier and NOTED on records protection of the supplier and NOTED on records

19 Association of Optometrists Litigation & Record Keeping Dispensing record Frame Facial measurements Lenses Sign acknowledgement form

20 Association of Optometrists Litigation and Record Keeping

21 Association of Optometrists Litigation & Record Keeping Data Protection Act 1998 Patient’s consent Taking recordsTaking records Keeping recordsKeeping records Passing records on to third partyPassing 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

22 Association of Optometrists Litigation & Record Keeping Access to medical records (Data Protection Act 1998) Px’s are entitled to: Explanation of original recordsExplanation of original records Copies of all the recordsCopies of all the records

23 Association of Optometrists Litigation & Record Keeping How long do we keep records NHS terms of service 7 years Recommendation: -Adults 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

24 Association of Optometrists Litigation & Record Keeping Who owns the records? Business Optometrist needs access to records Consider your position if you are a locum or employed and change jobs

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26 Association of Optometrists Litigation and Record Keeping Record Keeping Tips You should keep full records of the patient’s details, clinical details and dispensing detailsYou should keep full records of the patient’s details, clinical details and dispensing details The records should be clearly legibleThe records should be clearly legible The optometrist responsible for the examination should be identifiable from the record carThe 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 outIf you have not noted down the results of a test, it is assumed you have not carried it out

27 Association of Optometrists Litigation and Record Keeping It is no longer considered acceptable practice to use tick marks or the abbreviation ‘NAD’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 referralNote 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 sameWhether 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 recordsWhen you leave the employment ensure you have access to the records

28 Association of Optometrists Litigation and Record Keeping There is a strong correlation between poor records and no defenceThere is a strong correlation between 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

29 Association of Optometrists Litigation & Record Keeping 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

30 Association of Optometrists Litigation and Record Keeping


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