Manage clinical records

No one became an optometrist because they enjoyed keeping records, but that doesn’t mean it isn’t a vital skill, says Steve Smethurst.

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Good record-keeping is essential to good patient care. “Practitioners are responsible for what they write – or for what they choose not to write,” says Professor Nizar Hirji FCOptom, Consultant Optometrist at Hirji Associates in Birmingham. “Records are the most tangible evidence of the practitioner’s clinical practice and – in litigation – they may ‘illuminate’ or ‘cast a shadow’.” 

Responsible recording

“Poor record-keeping crops up all too often in fitness-to-practise cases,” says Natalie Michaux, GOC Standards Manager. “Sometimes it’s a case of not recording the basic minimum information when you have a consultation. Other issues might be around legibility of handwritten records. We know that – via general engagements with business registrants – these are still used by some. It might even be accessibility-related if records are stored in a cupboard and the optometrist who runs a sole practice goes away and takes the key with them. It’s things like these that you might not necessarily think about, but it’s all part and parcel of making sure that records are accessible to those involved in that patient’s care.”

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