Insight

Record Keeping: It’s All About the Details

Document, document, document. Comprehensive and accurate notes are important anytime you engage with a patient, but especially so when you encounter a challenging situation in your practice.  

As an optician, are you aware of your record-keeping obligations? Standard 5 of the College’s Standards of Practice (Record Keeping) outlines what must be included in a patient record. Aside from your obligations to keep accurate and fulsome notes, detailed documentation also provides a complete record of a patient’s history and shows the sequence of events regarding patient encounters. Documenting details about your interactions and communication with patients is likely to reduce the chance of there being a mistake and is a good way to avoid the kinds of miscommunications that lead to complaints. 

Record keeping is also important if the College does receive a complaint concerning your behaviour or conduct. One of the items usually gathered during an investigation is a copy of the Complainant’s complete patient record. The College’s Inquiries, Complaints and Reports Committee, responsible for investigating complaints, will review and examine the Complainant’s chart looking for details surrounding the Complainant’s concerns. The panel may be looking for information regarding the Complainant’s history, details of the prescription used to make the Complainant’s eyeglasses or the identity of the optician who dispensed the Complainant’s eyeglasses. Let’s review a few of the components that must be included in a patient record, which are the following: 

• A patient history, including information about the patient’s general and optical health, occupation, and relevant hobbies or other regular activities; 
• Complete details of a patient’s prescription, including a copy of the original prescription in a form that is unaltered from the manner in which it was received by the optician (e.g. photocopy or electronic scan), the name of the prescriber, and the date of examination; 
• All details of the contact lenses dispensed including any trial contact lenses or eyewear dispensed (such as frame and lens specifications); and
• The identity of the optician who fit, verified, and delivered the optical appliance.

The best way for you to demonstrate that the care you provided to the patient met the College’s Standards, is to properly document it. If necessary, your notes also serve as a refresher for you to remember exactly what happened during each of the patient’s visits. Many complaints involve a he/she/they said scenario, so it is paramount that your notes be fulsome and as thorough as possible. Good notes can help the panel decipher what really transpired between you and the patient. When in doubt, disregard the saying, “less is more”- rather, it’s all about the details. 
 

Daniël Jansen, Manager, Professional Conduct