One of the other optometrists told me he can’t read the writing in my clinical records, doesn’t understand my abbreviations and thinks that I should include more information in them. He feels that my poor notes are putting the patient at risk. What should I do?
In my role as an expert witness in medico-legal and fitness to practise hearings, I read a lot of other eye specialists’ clinical records. My estimate is that 95% of the cases I am asked to provide an opinion on involve very poor clinical record keeping.
I often see writing that is impossible to read, symptoms that are ignored and/or symptoms that the cause of is not identified.
The practitioner should aim to make it as easy as possible for the next practitioner examining that patient at a future date to understand what was said by the patient, what was done by the practitioner and the results of the tests conducted. This will help the next practitioner do the very best for the patient. When the next practitioner can’t read the entries in the clinical records and/or has to search back many years to find important data or the results of some tests have not been recorded mistakes can be made. This is not fair on the patient nor the next practitioner.
The clinical records must form an abridged record of what the patient said, what their eyes looked like inside and out if they had any past or present eye or health problems, what if any medicines they were taking if they had any past or present eye treatment and if anyone in their family had eye or health problems.
Here are some examples of poor record-keeping I have seen in the last ten or so cases I have been asked to provide an expert opinion on:
- Handwriting that is so poor it takes tens of minutes to decipher it if it is decipherable at all (this is not a problem when clinical data is recorded using keyboard entry).
- Using abbreviations that are not standard abbreviations; information is lost in this way.
- Being too lazy to write down names of medications and using the abbreviation ‘As B4’. This means that the next practitioner has to search through the records to find out what medicines the patient has reported taking in the past.
- Being too lazy to write the visual acuity for each eye and straddling the dividing line in the clinical record between where the right eye visual acuity should be written and where the left eye visual acuity should be written. This could be mistaken by the next practitioner as the visual acuity with both eyes together.
- Not recording the lens power of the current prescription. The next practitioner has to hunt through the notes to find the previous prescription. This also means that the lazy practitioner does not know what the previous prescription was and they might recommend the same prescription or a prescription that is weaker than the previous one even though the patient has explained that the current glasses are not strong enough.
- Not recording the monocular visual acuities with the previous glasses so the next practitioner has to hunt through the records.
- Not finding the cause of a ‘shadow’ in the vision and advising all is okay.
- Not finding the cause of ‘flashing lights’ in the vision and advising all is okay.
- Not finding the cause of intermittent vision loss and advising all is okay.
- Not taking heed of elevated intraocular pressure in one eye and advising all is okay.
- Not taking heed of a visual field defect in one eye and advising all is okay.
The next practitioner should not have to guess what is written in the notes, not and not be left to hunt for information. Writing clear, concise, easy to read and full clinical records are in the patient’s and the next practitioner’s best interests.