Record keeping, again!

Good practice in record keeping.

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Published: Spring 2012

In my clinical notes on auditing records and deciding whether or not visual field tests should have been done. I suggested that practices should have written guidelines, agreed by all the performers (optometrists and OMPs), for when visual fields would normally be done in certain categories of patients. This time I would like to talk about another aspect of record keeping that can only be ascertained by examining a reasonable sample of records, and that is unexplained similarity between clinical findings from one patient to another.

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