Record Keeping Foresight not Hindsight Trevor Warburton BSc FCOptom

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1 May 2009 Presentation handout AOP Web Site (under GOS and Regulatory matters) For flashes and floaters: For Freedom of Information follow GOS then FoI College of Optometrists (under guidance) For Flashes and Floaters see other guidance in members area GOC for legislation information (under legislation) Litigation & Record Keeping Optometry Today Aug pdf Staying out of trouble Will your record keeping help or hinder - Nov 08 Stockport LOC (for patient information sheets) TJW Freedom of Information publication scheme Data Protection and FoI

2 Record Keeping Why bother? Why keep records? Rules and Regulations Some principles Some examples Related issues Good clinical practice Aids future care of the patient Monitors trends Can provide DEFENCE when things go wrong Why bother? College Guidelines Section 35: The optometrist has a duty to ensure that he keeps complete and legible records of the patients under his care. GOC cases show: Failure to keep adequate records may constitute SPM Rules and Regs The Opticians Act 1989 GOC Rules GOS Contract Similar to previous regs Common Law Duty of Care Guidelines The Sight Test Opticians Act refraction with the intent to prescribe Sight Test Regs 1989 SI 1989 No 1230 The Sight Test when a doctor or optician tests the sight of another person, it shall be his duty: (a) to perform, for the purpose of detecting signs of injury, disease or abnormality in the eye or elsewhere (i) an examination of the external surface of the eye and its immediate vicinity, (ii) an intra-ocular examination, either by means of an ophthalmoscope or by such other means as the doctor or optician considers appropriate (iii) such additional examinations as appear to the doctor or optician to be clinically necessary; May

3 The Sight Test No internal examination? No external examination? One eye? GOS Regs E.g. to notify the GP after seeing a patient with Diabetes Glaucoma GOS Regs GOC Rules To refer to an ophthalmic hospital to the GP Inform the GP that he has done so Give the Px a written statement he has done so with details of the referral On referral for instance Updated in 1999, amended in 2005 Allow for discretion on referral Allow for referral via booking centres Require a record of referral to be kept Require a written report With booking centres, the urgency of the case to be indicated Common Law Litigation Duty of Care A practitioner should provide the same standard of care as that offered in a similar set of circumstances by a reasonably competent optometrist possessing up to date skills. i.e. The peer view May or may not be the same as guidelines Civil Cases AOP deals with hundreds annually GOC in 2006/ referred to GOC 22 progressed to full hearing Your records may be your best defence May

4 The Sight Test Opticians Act refraction with the intent to prescribe Sight Test Regs 1989 SI 1989 No 1230 Trends Cases referred No. cases Trends Trends Cases on the books at AOP Currently in excess of 1,000 ~ 10,700 contracted to GOS ~ 9% or 1 in 11 GOC Litigation OCCS Investigating Committee FTP Panel Key to a successful defence The right actions A good record of those actions Fully addresses the presenting symptoms Details your investigations May

5 Normal sight test procedures ocular Hx and symptoms Best spectacle correction and VA basic BV assessment external ocular examination intra-ocular examination through undilated pupil basic field screening for patients judged at risk by the optometrist tonometry for patients judged at risk of glaucoma by the optometrist maintaining records that show the results of the sight test issuing the prescription or statement giving verbal advice writing a referral letter, if required. Principles Record everything you do and do everything you record! Spot out of the ordinary cases Go the extra mile on recording Think defensively How would this look if? Consider recording findings which prove: You looked / investigated You considered alternatives Principles Record What the patient said What you said and did What you found What you didn t find! Your conclusions Your advice Patients have selective memories Symptoms become clearer with every professional they see!! Principles Test your own records Select a random record Why did the patient present? What did you do and not do? What was your advice? Would you be comfortable defending your actions if you were challenged? Principles Principles Reason for visit Past history Vocational requirements BV Refraction Int & Ext Ocular health Other investigations Advice given Not comfortable Comfortable Can fully justify Compare your own records A few years ago with now Most people find they are writing more now A record from my practice (not mine!) Handwriting May

6 How not to do it - 2! 4 7 Principles Tell the patient Keep notes of other Px interactions Advice by phone Advice in the waiting room Give advice in writing if necessary And record the fact Document all dispensing and repairs Keep it legible! Common complaint I wasn t told.. Shorthand Shorthand NAD not actually done or Means what, exactly? OPH R NAD not actually done or Means what, exactly? PUPILS (tick to agree) DCA, all 3 OK L May

7 Shorthand The abnormal NAD not actually done or Means what, exactly? PUPILS DCA, all 3 OK: Y / N An example that should keep you safe Not typical Well above average standard Not many seen by the AOP are like this May

8 Record features Records Oph. R Post. Oph. Pole: Photos? CD 0.4 IA01662ep3 InfDo Disc you haem need to write halo of detail ppaas well? A/V: 2/3 Early dry pigmentary mac changes Records We hear complaints about this How can I be expected to record all this? I don t have time Quote from a letter in Optician we are faced with the threat of a year or more of the totally ghastly, life-changing experience of a full hearing The Future PEARS Therapeutics Prescribing Record what it s not! May

9 Record reasons Normal record You may be wrong in the end! But the decision was correct at the time Based on the information available No such thing Record of a straightforward Px Records all findings of investigations relevant to the presenting symptoms Another situation My eye was all red this morning My GP said to see you I can see OK It s not sore It looks a mess May

10 What to record? c/o red eye from this am. Sent by GP. No pain or discomfort. Vision OK Explained this is sub-conj haem. Will clear in a week or 2. If it doesn t, or if any discomfort, see me or GP. Nothing is a common option VA: IOP: R 15 See pic IA0xxx R 6/6 L 6/6 (as previous) L 16 (as previous) For CL wearer: Cornea Clear, no stain. Where to record? For an existing patient On their record For a new patient Create a record or as a minimum Make a note in a day book Px name Brief advice Tonometry Record the time of the reading Saved one domiciliary practitioner Consider recording the type of drops GOC critical of one practitioner for not doing so Visual Fields If you don t keep the plot Note thresholds Type of plot 26pt MSST 26pt SSST 24/2 etc Store electronically... Complete EPR If your screener can output images Hensons can Humphreys can If you have imaging software May

11 Backup Vital for safety of your data Somewhere in the world A hard drive crashes every 15 secs 31% of PC users have lost all data Lifetime failure rate for hard drives is 100% They all fail eventually Backup My system backup Mirrored Drives Make regular backups Take them off site Keep them safe and secure Check the backup is working Database Archive Online May

12 Referral Letters These form part of your record They may provide more detail than your record Make sure they don t get lost Make them legible Illegible No DoB? Glaucoma No VF No Disc appearance No reason? No practice name No address No practitioner Typed Word processed Urgent Referrals Where are they going? Who did you speak to? Note it on the record and/or on the referral letter Send the letter with the patient (or fax in advance) May

13 A Case Age 56; Laser for hyperopia Still low plus, ST & specs supplied 9 month later, complains: Poor vision Went elsewhere, Rx Changed Wants refund. Records are poor!! How long to keep them? How long to keep them? Suppose you missed STR Limitation period 3yrs from the point of realising a negligent act has occurred Identified 2 years later, advanced Treated for 3 years, unsuccessfully Deteriorates further for a year or so Registered blind Someone says: what about when you saw that optician? 8 years on you get a letter.. How long to keep them? GOS Regs 7 years Not long enough! How long to keep them? AOP advise: 10 years for adults Children till they are 26 And it is 10 years since you last saw them The deceased for 10 years If your employer destroys them sooner It may be you that suffers May

14 How long to keep them? Treat appointment diaries as records Patients get confused about where they went If you are accused And you can t find a record You may have a problem If the diary and your records show you were seeing other patients You may be home and dry How long to keep them? What if a practice changes hands? In the contract of sale Require the records to be maintained safely Allow access in the event of a claim Rx & CL Spec. Legal requirement to provide Rx following a sight test CL Spec. following fitting and check-ups CL Specification Name & address of patient Name and Reg No. of practitioner Practice address Date fitting was completed Expiry date Sufficient details to allow replication CL Supply Supplier must arrange aftercare in so far as, and for so long as, may be reasonable in the particular case AOP & College view of aftercare Basic advice On lens care The need for routine professional care Contact details for emergency care Care & advice leaflets I provide at annual check-up Make a note on the record Make a virtue of providing the specification May

15 Data Protection Register with Information Commissioner if: Any personal data is held on computer Or could be E.g. field screener that could store records Make a virtue of providing the specification Data Protection Patient is entitled to: Copy of record Explanation of record You may charge Up to 10 for electronic information Even if supplied as hard copy Up to 50 for access to manual records Where hard copies are provided Data Protection Do you need consent to keep a record? Not written at present Legal advice says note verbal consent on record But doesn t Px consent by being there? If you take data off site Protect it!!! Encryption / password protection Don t leave it in the car Freedom of Information Statement of available information About the practice The practitioners Service provided Complaints procedures NHS fees Data protection Charges for information Freedom of Information 31 st October 2003 Publication scheme in place Saying how information is to be made available 1 st January, 2005 Public can request the information May

16 Freedom of Information Complaints Just complete the blanks Keep handy to supply if requested 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 Insurance Professional Indemnity Cover against being sued Defence Cover For the GOC Insurance Claims occurring cover Covers claims where original incident occurred during the period of cover Common in larger companies Probably does not cover work outside company Insurance cover for that period lasts for ever (but maybe not for GOC) Does not cover incidents prior to period of cover May be possible to buy run-on cover Insurance Mr A Age 70 April 2003 Mr A Age 68 April 2001 Claims made cover Covers claims made during the period of cover Common personal cover (AOP) Covers all periods prior to commencing cover No cover when insurance ceases Need to maintain cover during periods off work Buy run-off insurance on retirement Remember How will it look? May

17 Resources AOP Web Site (under GOS and Regulatory matters) For flashes and floaters: For Freedom of Information follow GOS then FoI College of Optometrists (under guidance) For Flashes and Floaters see other guidance in members area GOC for legislation information (under legislation) Stockport LOC (for patient information sheets) Litigation & Record Keeping Optometry Today Aug 04 TJW Freedom of Information publication scheme Data Protection and FoI June

18 Communication Trevor Warburton BSc, FCOptom Litigation and record keeping Better to be safe than sorry W e live in an increasingly litigious age in which consumers are encouraged to expect the highest standards, and to complain if they are not delivered optometry is no exception. Practitioners may find that they are asked to account for their actions by various different bodies, including the Optical Consumer Complaints Service (OCCS), the small claims court, higher-level courts and the General Optical Council (GOC). Membership of the Association of Optometrists (AOP) provides a comprehensive package of professional indemnity insurance against claims for damages and an in-house legal team, which provides advice and defence in disciplinary cases. Costs in GOC disciplinary cases can be in excess of 20,000, so if you insure elsewhere, make sure you read the small print and know what you are covered for. Some policies require that you adhere to particular guidelines and keep comprehensive records in order to maintain cover. If a claim crops up relating to a patient you saw five years ago, can you be sure the record will be comprehensive? Can you rely purely on an employer s insurance, rather than maintaining personal insurance cover? The answer is it depends. In a civil case, the patient will sue whoever has the deepest pockets. This is likely to be a company rather than an individual. In defending itself, the company will have to defend the actions of the optometrist, but even where the individual is not at fault, the company s insurer may choose to settle the claim early, possibly admitting negligence, in order to avoid the greater costs of lengthy litigation. But look at a different scenario; the optometrist does something the company regards as unacceptable. The company takes disciplinary action against the optometrist concerned, which may lead to dismissal. If the matter is then reported to the GOC, the company has no reason to assist, so the optometrist is now on their own. This is when personal insurance and defence cover is required. It may be unlikely, but that is the point of insurance. The AOP deals with hundreds of cases each year, both civil and disciplinary. Many can be dealt with at an early stage and prevented from progressing to courts or a tribunal. Of the 59 cases referred to the GOC in the year to September 2003, 45 were investigated and, after submissions by the AOP on behalf of the practitioner involved, did not proceed to a disciplinary hearing. The remainder required defending at a full hearing. What is clear is that one of Figure 1 Sample patient record card the keys to a successful defence is good record keeping. Whilst this is a mantra that has been heard time and time again, practitioners can still be heard complaining along the lines of, How do they expect us to find the time to write all this down? So although keeping thorough records is obviously good clinical practice, there is another entirely selfish reason for it; namely self-defence. As any practitioner who has been involved in a GOC hearing will testify, extra time spent completing records is a small price to pay. Whilst thorough and appropriate clinical investigations are obviously a necessity for all patients, a good record of those investigations increases the likelihood that the GOC Investigating Committee will not proceed with a hearing and, if it does, improves the chances of a successful defence. Notification of GOC proceedings brings with it over 12 months of stress, anxiety and uncertainty, with the possibility of erasure from the Register and loss of your livelihood. To quote from a recent letter to OT (12/03/04): we are faced with the threat of a year or more of the totally ghastly, life-changing experience of a full hearing. The strain that this puts on the practitioner and their family cannot be over-emphasised. Do not be the next practitioner to experience years of stress and strain. At the very least, ensure that your records will provide you with a fighting chance of a good defence. What is a good record? A good record involves writing down what the patient said, what you said to the patient, what you did, what you found, what you did not find and your conclusions, including your advice. You should think defensively, particularly in unusual cases. Ask yourself how the case will look if anyone questions you about it. If your record shows an increase in CD ratio from 0:2 last time, to 0:4 this time, and IOP from 14mmHg to 19mmHg, you may well think it all still looks normal, but just suppose it isn t? If you have not checked the visual fields you have no proof that there was no field loss at the time of the second examination and so will have more difficulty defending your actions. The courts and the GOC will not be interested in who might be paying for these procedures, only in the fact that you didn t do them. Try selecting a record at random from nine or 12 months ago. Ask yourself if you can tell why the patient presented to you. What did you do? What didn t you do? 20 August OT

19 Communication Trevor Warburton BSc, FCOptom Figure 2 Example of a patient information sheet What advice did you give? Would you feel comfortable defending your actions if you were challenged? Figure 1 shows a sample patient record card which would be regarded by the AOP legal department as being an above average example. We can see the patient attended because of a floater but had no light flashes. He is a driver, is not diabetic, has no previous ocular history and no family history. Pupils were dilated with 1.0% tropicamide and an information card was given explaining the rare side effects of mydriatics. There are minor lens opacities in the right eye and none in the left. The posterior pole was examined with a Volk Super 66 and the maculae were flat. The periphery was examined with a Volk Super Vitreo Fundus lens and there were no signs of holes or tears. Pupil reactions were normal; the AV ratio was 2/3 with no nipping; CD ratio is noted and the cups were round and central. Fundus photos were taken and the record number is noted. Slit lamp examination of the anterior vitreous showed no sign of pigment cells (tobacco dust). Visual fields were normal with a 26pt single stimulus supra threshold test and the thresholds are noted. This field plot is filed electronically and the reference number is given. IOPs are noted with the time, although a criticism might be the lack of any indication of multiple readings. The conclusion is that the patient has had a posterior vitreous detachment. He has been warned of further symptoms of retinal detachment and given a flashes and floaters leaflet that explains this. His driving licence has been seen as evidence of age for the Point of Service check and is noted for the future. His spectacles do not require change. Negative findings can be just as important as positive ones. Consider the situation above of examining the peripheral retina. A note of the mydriatic drop used will establish that you dilated if you felt this necessary. The type of ophthalmoscope will demonstrate how good the view was likely to be. Even the type of fundus lens used, since a Volk Super Vitreo Fundus lens will give a much better view of the periphery than, say, a 78D lens. The statement, Peripheral retina appears healthy, no sign of holes, tears or breaks, establishes not only that you found nothing abnormal, but also that you knew what you were looking for, as does, slit lamp no sign of pigment cells in the anterior vitreous. Not writing this down, or not using these techniques, does not of itself mean you are not taking reasonable care, but keeping a definite record does make it much more likely that any complaint will never progress to further action. Some aspects of record keeping can be reduced to circling the appropriate option, providing it is clear what this means. So Media 3, means absolutely nothing, but the statement Media clear? followed by Y/N options, which can be circled, make the meaning clear. Again, this allows for recording both positive and negative findings, although findings such as Media not clear should have an accompanying explanation. Not all patients will require as many investigations as this one and, if the test is NHS, you can charge if you feel that investigations are outside the remit of General Ophthalmic Services (GOS), so long as you have completed your GOS obligations. In addition to recording your findings during the consultation, make notes of other interactions with the patient even if these were on other occasions and not associated with a sight test or eye examination. If you give advice, either in the waiting room, or by phone, write it on the record and date it. Where appropriate, it is useful to give advice to patients in writing, making the usual note on the record. Pre-prepared information sheets on a variety of conditions leave no doubt as to the advice given to the patient (Figure 2). You should document all dispensing and repairs. For example, never submit repair vouchers for children without a supporting entry on the record. Sometimes, when a patient has some symptoms, you may choose not to pursue additional investigations. This could be because the investigations involve additional cost and the patient does not wish to pay, or because your feel the investigations are inappropriate for some reason. In this case, you should ensure that your records document all the reasons for your decision. If there is any risk that the symptoms could relate to an immediately sight-threatening condition, you should refer the patient to A&E. Always remember that you have a legal obligation to supply a prescription following a sight test, as well as a lens specification for contact lens wearers. If you have to re-check a patient shortly after a test, and find a refractive change, you should remember to issue an amended prescription. The time factor It can be many years after the event that a potential claim or disciplinary case becomes apparent. Potential claimants have three years after they first become aware of the right to claim in order to do so. In the case of children, the three-year period does not start to run until they are 18. Picture a case of missed potentially sight-threatening retinopathy. It may be another year or two before visual symptoms drive the patient to seek help. There may then follow a period of two or three years of treatment in the hope and belief that the situation is retrievable. Further deterioration may follow to eventual registration of blindness. Someone now suggests to the patient that it is surprising that the condition was missed all those years ago, so the patient starts to look into it. Another year goes by and you are notified of a claim against you for a patient you last saw eight years ago. GOS regulations only require you to keep records for seven years. If you don t have the record you have no defence and the courts will probably side with the patient. So how long should you keep a record? The AOP recommends that for the purpose of defending negligence claims, the records of adult patients should be kept for 12 years, and children s records should be retained until they are both 25 years old and it is 12 years since they were last seen. Records of the deceased should be kept for 10 years. This advice is based in part on Department of Health recommendations for the minimum period clinical records should be kept after the conclusion of treatment. The College of Optometrists agrees with this. The Data Protection Act stipulates that data should not be kept longer than is necessary. This is a balancing act, and is open to interpretation. Some practices have a policy of destroying records after as little as five years. You should remember it is the practitioner who will suffer if they have no record to defend themselves. When a practice changes hands, or closes, the records still require safe keeping. Just because the practice is closed does not mean a claim cannot arise some years down the line. When a practice is sold it would be wise to insert a clause requiring the new owner (and any future owner) to maintain the records safely, and to allow you access in the event of any claim. What should you do if you are an employed or locum practitioner and your employer holds the records? It would be worth asking for a written statement of the 22 August OT

20 Communication policy regarding records and discussing the matter if you are unhappy with the answer. You need to ensure that you will be able to obtain access to the records if you are called on to defend a claim, as it will be your problem rather that your employer s (especially if a lay employer) if the records are not available in the event of a claim or disciplinary action. Whilst access to the records should ultimately be available under section 35 of the Data Protection Act 1998, this is of no help if the records have been destroyed. It is always worth regarding the appointment book as a record and treating it the same way. Patients sometimes get confused about which practice they visited and when. If allegations are made against you, and you cannot find a record, you have a problem. If the appointment book shows that the patient did not attend when they say they did indeed, shows that others attended on that day and you do have their records then you are in a much stronger position. Conclusion Generally, in the event of a claim or disciplinary case, you will be judged against the standard of the average reasonably competent practitioner. This is a moving feast, as standards change over time. Thirty years ago, it was unusual to check IOPs; now it is the norm (although the practitioner should only be judged by the standards of a reasonable optometrist that were in force at the time of the incident). The exception to this rule is where a practitioner claims a particular expertise. So someone describing themselves as a specialist paediatric optometrist will be judged against the average, reasonably competent specialist paediatric optometrist. How can you know what is average? Attending peer review groups is one excellent way of seeing how other practitioners practise, especially for those practitioners who work alone. Write down every event in every patient interaction, whatever it is, at the time. Audit your own records from time to time, as if you were about to present them to the GOC Disciplinary Committee. Be brave enough to ask a colleague to comment critically on how you are performing in this vital area. All of this may seem a pain when you are busy; it can seem much easier just to write NAD (not actually done) but remember, the spare tyre in your car boot is a waste of space most of the time - until you need it! About the author Trevor Warburton is an AOP Director, Chairman of the AOP Professional Services Committee and an independent practitioner in Stockport. 23 August OT

21 CLINICAL Short clinical case record - a classic insight Remember to carry out your work properly, or not at all, uses his experience of disciplinary cases and record keeping to remind practitioners of an important message - that by answering the necessary question in full, you help yourself and your patient. You have a duty of care to the patient which can be discharged either by seeing them, or by advising them to see someone else who is in a position to make appropriate and timely investigations. If you do see them yourself, you need to do a proper job. To do less can leave you vulnerable Everyone will have had the patient who presents telling you that their GP has asked for a quick pressure check. Tempting as it may be to simply perform tonometry, write down the numbers and give them to the patient to take back, this is not actually in anyone s best interest, especially yours if things are not straightforward. This was precisely the scenario when Mrs A walked into the practice. She had never been to us before, but clearly expected the process to take no more than a minute or two. As ever, we patiently explained that the question that the doctor was really asking was does this patient have glaucoma?, and that they only asked for pressures because they don t know what else to ask. We explained that many patients with glaucoma have normal pressures and so rather more investigations are called for than just a simple pressure check. Mrs A accepted the argument and made an appointment to return for an eye examination. At the examination it transpired that she had been waking during the night with severe pains in one or both eyes, more commonly the left, for a couple of months. She was hypermetropic, with a small prescription change producing acuities of R 6/6 and L 6/6pt. Intra ocular pressures were well with normal range at R12 and L14 mmhg and her central visual fields showed no defects. Examination and photographs of the fundi showed moderately large disc cupping, but these were round and central, with a health neuro-retinal rim. With the standard triad of tests all Slit lamp examination: Revealed stunningly narrow angles when judged by Van Herick looking fairly normal, attention turned to slit lamp examination which revealed, apart from mild Blepharitis, stunningly narrow angles when judged by Van Herick between grade 0 and grade 1. A series of sub-acute or pro-dromal attacks of angle closure seemed a possible explanation. A letter was written to the GP advising referral to the eye clinic soon for assessment and possible provocative tests. The patient was advised that if an attack became severe they should attend the Accident and Emergency department immediately. The patient was seen in the eye clinic within two months and the diagnosis confirmed. She was started on pilocarpine as a temporary measure and was listed for bilateral laser iridotomies soon. Interestingly, further questioning by the consultant revealed the information that if she switched on the light during one of her attacks at night, the pain eased off. This case demonstrates the general advice that you should either do things properly, or not at all. The pressures would have provided no useful information on their own. Indeed, they may have erroneously led the GP to believe all was well. Patients don t ask about the service you provide with contact lenses, they ask about the price because they don t know what other questions to ask. It is the same with the GP, so when asked for pressures (or anything else), you need to read between the lines and decide what the real question is. Then either answer it in full, or not at all. Patient record card: It is vital to keep good records Trevor Warburton practises in Stockport, and is chairman of the AOP 20 December OT

22 PRACTICE ADVICE Staying out of trouble Will your record keeping help or hinder? By 40 28/11/08 RECORD KEEPING Sample record: This sample record uses the quick selection of Y/N for items with a definitive answer (e.g. driver?). It also allows for quick recording of routine advice and of any information given to the patient. Cataract is recorded on an arbitrary numeric scale where 0 is clear and 5 is opaque. Ophthalmoscopy has written notes; there can be no doubt in this case that the retina was viewed and the macula was seen for both eyes and they were OK. The visual field result is recorded, but the plot has also been stored as an image in imaging software. Non-standard advice is clearly recorded. There are all manner of circumstances which lead patients to make complaints about a practitioner or practice. Some have a genuine grievance, some mistakenly believe they have a genuine grievance and a minority are simply vexatious complaints, with little real merit. I have written previously about the need for good record keeping (OT August ) and the article is still available in the OT archives, and has recently been reproduced in the Optometry Red Book. If you receive a complaint, it is too late at that point to think I wish I had written down x, y or z. This article will look at a few of the issues that cause patients to complain and consider what is required within the records to adequately defend the actions of the practitioner. To begin with, it is worth understanding the potentially escalating pathway for patient complaints. Generally they will complain first to the practice. If this complaint is in any way about clinical performance you should immediately consult your professional indemnity insurers. They may also complain to the NHS locally. In some cases the NHS will investigate and in others they will pass it on elsewhere (eg, the GOC). The patient may also complain to the Optical Consumer Complaints Service (OCCS) or to the GOC directly. If the complaint is about product, then the GOC will pass it to OCCS. If it appears to be about a clinical matter or professional conduct, then the GOC Investigation Committee (IC) will look at the case. You should be aware that there is no such thing as a brief look and dismissal of a case by the IC. They will require copies of all paperwork and records relating to the case from both sides. It will all take some time, creating an extended anxious period for the practitioner. The result may ultimately be the dismissal of the case, or referral to a Fitness to Practise (FTP) panel or, in some cases, the IC may ask for a performance assessment, which is a relatively new addition. Some cases have gone to an FTP hearing where the charges bear no real relationship to the original patient complaint. For instance, the original complaint may have had no merit, but the case brings to light poor record keeping, which then becomes the subject of a hearing.

23 PRACTICE ADVICE On the non-clinical side, problems of some sort with spectacles are the most common complaint and, thankfully, these are mostly dealt with effectively by the practice to the patient s satisfaction. Sometimes it simply needs adjustments to the frame, or the prescription. On other occasions the patient just loses confidence and, rightly or wrongly, wants their money back. It is always worth remembering that if you leave a patient dissatisfied, then a few of them will find other ways to complain. If their complaint is dismissed by OCCS, a few savvy ones realise that changing their complaint slightly to cast doubt on the clinical side means that the GOC will also look at it. Don t leave a patient dissatisfied if you can possibly avoid it; refusing a refund can sometimes turn out be a very bad decision, so make them early and amicably! Cataract Still a major cause of complaint clinically is a patient not being informed about some aspect of the condition of their eyes, with the most common being cataract. It happens easily; the patient appears to have no symptoms or complaints; the vision is slightly down in one eye, say 6/6 down to 6/9+, and a small amount of cataract is observed in the affected eye. It may seem a reasonable decision to avoid worrying the patient by not telling them about the cataract. Suppose it later turns out that the patient was concerned about the reduced vision but they simply didn t like to say so they were waiting for you to raise the matter. So they go somewhere else a few months later and are told well, you have a bit of cataract in that eye. Next thing you know, you are on the receiving end of a letter of complaint. This may seem to be about a trivial matter, but it won t seem trivial if it ends up at the GOC. How do you protect yourself against this situation? The first point, obviously, is to always tell patients about conditions like cataract. The problem is; when is an ageing change in the crystalline lens a cataract? Many would argue that, with dilation, you can find some degree of lens opacity in everyone over the age of 60. So when is an ageing change a cataract? A good guide for this purpose is to call it a cataract when it is producing some noticeable or measureable effect on the vision or is easily visible to you. Earlier than that you may choose to refer to it as an ageing change, but nevertheless it is good safe practice to record it and to tell the patient about it. It may even be that the practitioner did explain it away as an ageing change without mentioning cataract, so the next important point is to ensure that you document any explanation given to the patient on your record card, and that you have also documented the cataract itself. So when the complaint is that I wasn t told or that practitioner is incompetent because they don t know how to identify cataract, your records will show otherwise. If you provide any written information to the patient, document that also. Macular Degeneration As far as civil claims go, it might be fair to say that wet macular degeneration shows signs of being the new flashes and floaters. Now that there are treatments available for wet AMD, there is also the possibility of a claim if the patient believes it was not identified early enough. The performance of Photo Dynamic Therapy (PDT) as a treatment was always suspect. Even NICE said that, on average at 24 months, patients treated with PDT have just one line of vision more than those who received no treatment 1. Time marches on, and PDT has been replaced by anti-vegf injections which are proving to be more effective. This makes it ever more important that wet AMD is identified and referred effectively, and ever more likely that claims will arise where a patient believes it was not. This does present a challenge since, although wet AMD is a fairly sudden onset condition, a patient who begins to notice effects a couple of weeks after a sight test might start to wonder if it should have been spotted. Your record needs to show VA and, if this is worse than your previously recorded findings, then there should be a reason (cataract is an obvious one). Ophthalmoscopy should have some indication that the macular area, or posterior pole, was normal. If a patient, especially an elderly one, returns complaining of distortion with new spectacles, at least consider the possibility that it may not be the spectacles. Check the VA and show them an Amsler chart. Look at the fovea. Make a note of all these tests. Then change the varifocal type! Dry macular degeneration is more difficult, but the risk of the I wasn t told complaint is still there. Where vision is affected, some explanation to the patient is obviously required, but it is more difficult in those patients who have a mass of soft confluent drusen and some pigmentary changes, but no apparent deterioration in vision. Unlike cataract, there is no consolation of a potential treatment. It is reasonable to explain such signs as ageing changes and it might be considered best practice to explain that these changes carry a risk of affecting the vision, along with giving advice not to smoke and to protect the eyes from bright light. Opinions vary on the value of nutritional supplements, but the AREDS study 2 suggests that their vitamin mix can potentially give a 25% reduction in progression from intermediate to advanced AMD. If you do not feel comfortable discussing nutritional supplements, consider giving the patient written information that points them or their family to the AREDS study on the internet. A useful tip 3 arising out of the AREDS study is a four- point scale for assessing the risk of AMD progression. Count one point for large drusen of 125 microns or larger (about the size of a vein at the disc margin) and one point for any pigmentary change. Score each eye separately and then add them together for a score out of four. A full score of four points means a 50% chance of progressing to advanced AMD in the next five years. Three points gives a 25% chance, 20 points a 12% chance and with one point the risk is just 0.5%. Never forget that patients with dry AMD can still develop wet AMD. Providing a home Amsler chart and instructions on its use is a good safeguard for both the patient and yourself ( Retinal Detachment Flashes and floaters are still out there and there has been plenty of information about good practice in dealing with them, including journal articles, College advice and an audio discussion in an issue of Optometric Quarterly. It is becoming very difficult to defend actions that do not conform to good practice. With stable floaters over two months old you will need to make a judgement but, for more recent onset floaters or flashes, your record will need to show in addition to the normal findings: Dilation Examination of the vitreous with a slit lamp Negative or positive findings of tobacco dust Examination of the peripheral fundus with indirect ophthalmoscopy Advice and warnings given to the patient, preferably in writing Do not refer recent onset flashes or floaters, or suspect retinal tears, via the GP unless you have established that the GP will be able to make an immediate (within 24hours) referral to an eye department. If you are unable to examine a patient with recent floaters, remember that flashes and floaters should be treated as a 41 28/11/08 RECORD KEEPING

24 PRACTICE ADVICE others to draw conclusions. Then if any questions are later raised about the referral, it is entirely clear why you were referring the patient /11/08 RECORD KEEPING retinal tear until examination shows otherwise. This means that, for safety, recent onset flashes and floaters that you do not examine require referral to an eye unit within 24 hours (College advice), via A&E if necessary. In any situation where you have dilated the patient s pupils, it is good practice to provide some form of written advice regarding the effects of dilation. Glaucoma It goes without saying that it is important to be certain, at the conclusion of any sight test, that the patient does not have glaucoma or, indeed, any other sight threatening condition. Practitioners make that decision many times every day. Sometimes the decision is easy and sometimes it is not. In a few cases, that patient will go on to develop glaucoma in the future. Usually this is a slow process, but occasionally it progresses much faster. Patients who suffer from an aggressive form of the condition, yet who are told it is normally slow to progress, can start to wonder if it should have been detected sooner. You need to be sure that your records demonstrate that you did not miss an early manifestation of glaucoma. This does not mean that you have to do every test on every patient to feel safe. Indeed, it is by no means certain that this would help as there becomes the danger of not seeing the wood for the trees. It does mean that you need to document intraocular pressures and C:D ratios for adults at the very least. If the patient has a family history of glaucoma, ensure that fact is noted on the record. At all times you need to stay alert to the need for further tests. The pressures may be 15mmHg R&L at the moment and, whilst the C:D ratio is 0.6 R&L, you have observed that the disc is large, the cup is round and central and the neuro-retinal rim looks healthy. Therefore you have decided, as the patient is only 42, you don t need to do a visual field. If you have written down all that information, then the decision should be seen as a reasonable one, even if the patient later develops glaucoma. If all your record shows is IOP and a C:D of 0.6, then you invite later questions that you cannot defend. If you make a referral, whether for glaucoma or anything else, it is as well to be explicit about your suspicions. If you suspect glaucoma, then say so, don t simply list your findings and leave GOS Primary care organisations monitor sight tests, vouchers and repairs looking for outliers. Who does more repairs than average? Who does more early sight tests? There is nothing wrong with being an outlier if your claims are valid. So long as all your repairs for children are documented there is nothing to worry about. You may also be able to point out an obvious explanation such as being very close to the largest primary school in the area. Likewise, you may have acquired a reputation for problem solving and dealing with difficult cases, so you tend to have more than the average number of patients presenting with symptoms or concerns. This is fine; the important thing is that your record clearly documents the reason or justification for the early sight test, or for that tint or prism. It is wise to note early retest codes on the record as well as on the GOS1 form so that you are quite clear about your reasons. Records If you use any non-standard abbreviations in your records then you should keep a list of those abbreviations explaining their meaning. There is a useful list of standard abbreviations in the College Guidelines. If you have a number of optometrists in the practice, or regularly use locums, then it is a good idea to make that list available in each consulting room for every optometrist to see. So your records need to be a complete account of your interaction with the patient and they need to be capable of justifying the tests that you did or did not perform and do keep them legible! They are supposed to assist with continuity of care, so do ensure that those who see the patient after you can read the record easily. Finally; do unto others as you would have them do unto you. Don t criticise a colleague s previous encounter with a patient without a full knowledge of the history. In fact, don t do it even then. You wouldn t want them to do it to you. It is a fact that many civil claims and complaints to the GOC only start because a second or subsequent practitioner makes a passing remark that criticises the actions of the first practitioner. This is rarely done vindictively, although it is frequently done to make the second practitioner appear more knowledgeable or experienced in the eyes of the patient. These idle remarks can create a quite unjustifiable cascade of events that cause an enormous amount of stress and anxiety. We can t stop other professions from doing it to us, but we can at least not do it to each other. About the author Trevor Warburton is an AOP director and clinical advisor to the AOP Legal Services Department. He is an independent practitioner with his own practice in Stockport. References 1. NICE Press Release 2002/ 0051 Issued: October Age-Related Eye Disease Study Research Group. A Randomized, Placebo-Controlled, Clinical Trial of High-Dose Supplementation with Vitamins C and E, Beta Carotene, and Zinc for Age-Related Macular Degeneration and Vision Loss: AREDS Report No. 8 Arch Ophthalmol October ; 119(10): FL Ferris et al. Four-point scale developed to simplify AMD risk assessment Ocular Surgery News January