Quality in Optometry Record Card Keeping. The Quality in Optometry (QIO) visits to practices commenced in May 2018. During this time we have noticed reoccurring themes and thought it would be helpful to share our findings to support contractors to meet their professional or contractual obligations. The standard of clinical record card keeping has been found to be extremely variable. Unfortunately a significant number of record keeping assessments have been graded as poor. This communication will act as an aide-mémoire and focus on what is an acceptable minimum standard of recording in a patient s record card following a GOS eye test. We would like to point out that we are aware that clinical and professional standards are constantly changing and as a consequence we are attempting to support clinicians with their record keeping using guidance issued by the Optical Confederation. We note for example some 12 years ago the recording of anterior chamber depth by the Van Herrick grading technique was hardly ever recorded. At present more and more practitioners are recording Van Herrick grading and in the next 10 years this could well be expected to form part of a routine eye examination. Historically the same has applied to the measurement of intra ocular pressures. Currently if a patient is over 40 years old and does not have a written record of IOPs having been measured, then this would be regarded as negligent practice. We note that many optometrists also now record the IOPs of patients in a younger age group. The standard expected is that of a competent optometrist who has kept up to date with clinical standards and is taken from the guidance on record keeping which is available from the College of Optometrists, which includes a section on what to
record. The full guidance can be found at https://guidance.college- optometrists.org/guidance-contents/knowledge-skills-and-performance- domain/patient-records/#open:566,58,322. The AOP has produced guidance on record keeping for their members which can be found at www.aop.org.uk/advice-and-support/clinical/clinical-governance/safepractice-record-keeping and ABDO and FODO provide guidance to their members on request. Please note we would strongly encourage all clinicians to familiarise themselves with these guidelines and to review them regularly. We will continue to signpost practitioners to these websites and guidance documents and would like you to note that this bulletin provides a helpful summary only. It remains the responsibility of each clinician to keep themselves abreast of standards set by their professional body. What to record It is very important that the presenting symptoms are addressed. For example records have been audited where the presenting symptoms are noted as headaches but then appropriate tests have either not been carried out or have been carried out but not recorded. Additionally, if any concluding advice given to the patient about their presenting symptom is not recorded then we have no assurance that the presenting symptoms have been addressed. When a patient attends with symptoms of headaches some further information is expected, for example:- when did they start, location in head, what if anything gives relief, are they associated with specific visual tasks, are they getting more intense. Although not expected to be carried out on every patient, a person presenting with headaches should have recorded examination results of pupil reactions, motility and more extensive ocular muscle balance tests (as opposed to a basic cover test). Consideration also should be given to performing visual fields. This is not an exhaustive list and the decision to do a particular test rests with the clinician, but if an appropriate test is not performed the reason for not doing it should be clearly recorded. 2
It is important to remember that a GOS sight test is an entity in itself i.e. all appropriate tests have to be undertaken on that day and recorded contemporaneously. Abbreviations The use of abbreviations should be restricted to the ones listed on the College of Optometrists web site. The use of the abbreviation NAD, although previously widely used should now be avoided. Additionally writing just normal or the use of ticks is not good practice. As professional clinicians, and not technicians, the choice of tests undertaken must be decided by the optometrist. However, unless there is a good clinical reason why a test is not done (and the reason for this decision recorded), the following is a list of expected tests to be carried out and recorded: The list below is taken from NHS England s GOS contract monitoring form and also maps to the Quality in Optometry checklist. Symptoms/reason for visit: - Record presenting symptoms. If it is a routine test/ recall then record something similar to routine check/ asymptomatic. General Health: - A brief statement of past medical history and ongoing problems. Medication: - Record current medication; preferably the name of the medication as opposed to e.g. tablets for arthritis if known by the patient. It is not good practice to record as before. Asking the patient to bring their present printed medication list to their appointment is a good idea. Ocular history: - with some indication of when the condition was present. e.g. year of cataract extraction and which eye. Family Ocular history: - Ocular history of close family members to include for example Glaucoma. Unaided vision/vision with present spectacles: -To be recorded right and left separately as well as with binocular if practitioner wishes. 3
Binocular vision assessment should be recorded for both distance and near:- Distance - As a minimum a basic cover test. More in depth tests e.g. (fixation disparity) especially with patients presenting with possible binocular vision issues or with significant changes in prescription or a new prescription. If prisms are prescribed the notes should show clearly why they were prescribed, and what muscle balance anomaly they are managing. Just continuing with the same prismatic correction as a previous test, without reassessing it is not acceptable. Near - Notes as per binocular vision assessment Distance. Refraction result: -The standard of recording is usually good. Visual acuity should be recorded both distance and near:- Distance: - It is expected to see a recording of right and left separately. Some clinicians also record, in addition, the binocular VA. (Useful particularly if a driver). Near - Notes as for VA Distance. Binocular on its own not acceptable. External examination: -Notes for right and left eye should be recorded. The use of phrases like all normal is not sufficient. Use of just ticks is not acceptable and it must be clear that both eyes have been examined and the results recorded separately. The use of terms like left same as right should be avoided. Notes should be made on at least lids, lashes, cornea and conjunctivae. Internal examination of the eye: - Notes for right and left eye should be made. The method used should be recorded if not by hand held ophthalmoscope e.g. volk super field. Use of phrases like what seen all normal should be avoided. Notes should be made on the media, blood vessels, maculae, discs and peripheral fundi. It s important that you record what you have examined. Many practitioners are now recording for the retinal periphery all four quadrants examined, all flat, no tears. Consideration should be given to performing a mydriatic examination. If some areas of the fundi are not able to be examined, then record the reason and if not dilated then the reason why. If it is a young child with poor fixation then record something like fleeting glimpses only 4
If you decide to use drugs during the examination (e.g. for mydriasis, cycloplegia, contact tonometry) then the drug and strength need to be recorded together with the expiry date and the batch number. Advice should also be given to the patient on possible adverse reactions and what to do, preferably in writing, and recorded on the record card. C: D ratio: - Notes for right and left eye should be made. Although not essential it is noted that more practitioners are making notes relating to the ISNT rule. Tonometry (where relevant):- If done by non-contact methods three readings should be taken. The time should also be recorded. If contact methods are used then the method should be recorded as well as drugs used, expiry date and batch number. Visual fields: - These should be undertaken if presenting history, symptoms or findings indicate. Some practitioners undertake fields routinely and should usually be carried out on those with glaucoma risk factors, such as a family history.the instrument used and the name of the programme selected should be recorded. If totally normal this can be recorded as such on the record card but a suspicious or defective result then a printout should be attached to the record card or saved electronically. If clinically visual fields are indicated but the practitioner decides it s not best/possible for the patient, then their reasons should be noted. Were all tests (core and additional), appropriate for this patient undertaken? e.g. Children, patients presenting with symptoms: - This is up to the clinical judgement of the practitioner. For children however it is expected that motility, pupil reactions, stereopsis, convergence, amplitudes of accommodation and, for a male child, colour perception should be performed. Appropriate advice given: - This needs to be related to the clinical findings and presenting symptoms. Record card is legible: - This can be a significant issue with hand written recorded notes. They should be able to be read by others without asking the practitioner who actually made the notes. 5
Is it easy to identify from the records which performer undertook the sight test: - As a minimum the practitioner s initials should be recorded on the record card. Full name would more advisable. Relying on recognising a performer s handwriting is not sufficient. Referral/letter copies: - These should be offered to all patients. General Points:- It has been noted on many record card systems (paper and computer) that there are often numerous boxes/fields where a test result can be recorded e.g. ocular muscle balances. It is preferable that all practitioners in a practice record the results in one nominated area. The areas for recording advice to patient are often omitted/very small and an area for free text is often not present. These are important fields and some record cards would benefit from a complete re design. A postcard size record card is too small to record all the points that are presently expected to be recorded. NHS England South West (South) Eye Care Team August 2018 england.optometrysouthwest@nhs.net 6