Litigation & Record Keeping

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

2. Litigation and Record Keeping Record keeping Why do we keep records? • Patient benefit • Monitor trends • DEFENCE OF OPTOMETRIST What records do we keep? EVERYTHING

3. Litigation and Record Keeping Attacks • Px complaint • GOC • Solicitors • Health Authority • OCCS • Health Ombudsman

4. Litigation and Record Keeping • Current GOC Trends

5. Defending the Optometrist Interrelation of Complaints Px Complaint Solicitors GOC OCCS PCO’s letter

6. Defending the Optometrist PCO’s GOC PCO Tribunal NHS (fraud) GOC Local resolution Crown Court HealthcareCommission FHSAA GOC

7. Litigation & Record Keeping What records do we keep? Patient information Clinical Dispensing Computerised or on paper? Content remains the same

8. Litigation & Record Keeping 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

9. Litigation & Record Keeping Clinical record Patient information (continued) Family history Ocular history Health Medication • History • Symptoms MAKE ENTRIES IN EVERY CASE

10. Litigation & Record Keeping Clinical record Examination Observations – right and left External - structures Ocular motor Motility Pupils NPC Internal Media Vessels Discs Macula Periphery Note   nad 

11. 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

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13. Litigation & Record Keeping Clinical record Refraction Vision – unaided Record the prescription found Visual acuity Record prescription issued NOTE ADVICE AND RECOMMENDATIONS

14. Litigation & Record Keeping 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

15. Litigation & Record Keeping 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

16. Litigation & Record Keeping Clinical record Contact lenses • Px compliance • Conclusions & advice & actions • Date of next appointment Note if they do not attend

17. 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 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

18. Litigation & Record Keeping Dispensing record Frame Facial measurements Lenses Sign acknowledgement form

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20. Litigation & Record Keeping 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

21. 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

22. Litigation & Record Keeping 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 realisinga negligent act has occurred

23. 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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25. Litigation and Record Keeping 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

26. Litigation and Record Keeping • 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

27. Litigation and Record Keeping • 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

28. 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

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