Transcript No Slide Title

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