record keeping Flashcards
(15 cards)
What is the primary purpose of maintaining patient records in optometry?
The primary purpose of maintaining patient records is to ensure continuity of care, patient safety, legal protection, and to comply with regulatory standards such as those set by the General Optical Council (GOC) and the Data Protection Act 2018.
What should be included in a patient record?
Personal details (name, age, address)
Reason for the visit
Clinical findings from examinations
Test results (e.g., visual acuity, tonometry, refraction)
Diagnosis and treatment plan
Discussions with the patient, including advice and decisions made
Signatures or identifiers of those involved in the consultation.
What is the GDPR, and how does it affect patient record keeping in optometry?
The General Data Protection Regulation (GDPR) sets guidelines for the collection, storage, and sharing of personal data. Optometrists must ensure patient records are stored securely, remain confidential, and are only shared with patient consent or when legally required.
How long should patient records be retained?
: Patient records must be retained for 10 years for adult patients and until the patient reaches 25 years of age for children, or as required by professional guidelines.
Why is accuracy important in record keeping?
: Accuracy ensures that all clinical decisions are justified, provides continuity of care, and helps protect optometrists in case of legal challenges or complaints. It also ensures the correct treatment and follow-up for the patient.
What are the consequences of poor record-keeping in optometry?
Medical errors or missed diagnoses.
Legal issues if there are complaints or claims.
Inconsistent care if another practitioner cannot follow the treatment plan.
Breaching patient confidentiality, leading to loss of trust and potential legal ramifications.
What should be done if a mistake is found in a patient record?
it should be corrected promptly by:
Amending the record with a note explaining the correction.
Not deleting the original entry to maintain the record’s integrity.
Notifying the patient if the error impacts their care.
What steps should be taken to ensure the security of electronic patient records?
Data encryption to protect records from unauthorized access.
Regular backups to ensure data is not lost.
Access control by using secure logins and passwords.
Training staff on privacy and confidentiality practices.
How should confidentiality be maintained in optometry practices?
Securing patient records (both physical and electronic).
Limiting access to patient data to only those who need it for treatment or legal purposes.
Discussing patient information in private settings.
Ensuring that patients are aware of their right to confidentiality.
What is the role of clinical imaging in record keeping?
Clinical imaging (e.g., retinal images, OCT scans) should be properly documented, clearly labelled with patient details, and stored in the patient record for future reference. Images should be compared with prior images to monitor changes over time.
: How can optometrists ensure continuity of care when patients are referred to another practitioner?
Continuity of care is ensured by:
Sending comprehensive records with the patient’s history, examination results, diagnosis, and treatment plan to the referred practitioner.
Obtaining patient consent before sharing records.
Documenting all referrals and communications in the patient record.
How should paper-based patient records be handled?
Kept in a secure location to prevent unauthorized access.
Filed properly for easy retrieval.
Shredded when no longer needed or when the retention period has passed.
How can electronic health records (EHRs) benefit optometry practices?
Providing easy access to patient records, reducing errors.
Allowing for better coordination with other healthcare providers.
Offering better data analysis for patient outcomes, treatment planning, and research.
What does informed consent involve in the context of record keeping?
Informed consent involves ensuring that patients are fully aware of:
The examinations and treatments they will receive.
The use and storage of their medical data.
Their right to access their records and request corrections.
What should be done if a patient requests access to their records?
Patients have the right to access their records under the Data Protection Act 2018. When a patient requests access:
Provide a copy of their records within a reasonable timeframe (usually within 30 days).
Ensure clarity by reviewing the information with the patient if needed.
Charge a reasonable fee if applicable, depending on the jurisdiction.
