Record keeping and guidelines 2 Flashcards Preview

Clinical and professional practice > Record keeping and guidelines 2 > Flashcards

Flashcards in Record keeping and guidelines 2 Deck (20):
1

what 4 things does the CoO “Guidance for Professional Practice" recommend about Develop and maintain knowledge and skills

- You must keep your professional knowledge and skills up to date and this includes: the law, College and other guidance, developments in practice.

- You should regularly review your work.

- You must work within the limits of your competence.

- You must meet the General Optical Council’s requirements for continuing education and training (CET).

2

what are the rules of the GOC requirements for continuing education and training (CET) and what does the CoO encourage about this

Currently 36 points required over 3 years, minimum of 6 per year. Must include peer review and interactive CET. Must cover range of topics.

The College encourages you to take responsibility for, and participate in, professional development beyond CET requirements.

3

what does the data protection act cover

all person identifiable data

4

what are all practices required to have

a registered “data controller” as defined under the terms of the act (who is responsible for that data)

5

list 5 things that the data protection act relates to

- keeping accurate patient data

- using the data for specific purposes

- amending inaccurate data and responding to objections from patients if the use of the data causes harm or distress

- keeping the data confidential and secure

- Patients, or person acting on behalf of a patient, allowed to access data for the length of time that you keep the records

6

what 4 types of record does the data protection act refer to

- hospital records
- children and young people
- general
- patients involved in clinical trials

7

how long are hospital records recommended to be kept
and what does the CoO and AOP recommend in relation to this

- 10 years
- CoO and AOP recommend adult patient records should be kept this long by optometrists

8

how long are records of children and young people recommended to be kept for

until the patient’s 25th birthday, or 26th if young person was 17 at conclusion of treatment; or 8 years after patient’s death if death occurred before 18th birthday

9

how long are general records recommended to be kept for

8 years

10

how long are records recommended to be kept for for those involved in clinical trials

15 years

11

which 2 types of people are allowed to access a patient's health record

- the patient

- an applicant acting on behalf of a patient:
Child’s parent
Someone authorised in writing by the patient
A person authorised by the court to manage the affairs of a patient incapable of doing so for themselves

12

which 3 types of applicants can act on behalf of the patient to be allowed access to the patient's health record

- Child’s parent
- Someone authorised in writing by the patient
- A person authorised by the court to manage the affairs of a patient incapable of doing so for themselves

13

under which 2 conditions can, access to records that must be granted (application must be made in writing) be accessed and what can the optician do

- Within 21 days for records relating to examination within the past 40 days
- Within 40 days if the examination occurred more than 40 days ago
- You can charge a fee – maximum is usually set at £10

14

what 3 things does the data protection act 1998 also relate to

- assisting the patient to understand their record by explaining its content and abbreviations

- satisfying yourself that there is no further need of the record before destroying it

- disposing of any records securely

15

list 3 points the data protection act makes about consent from the patient and what the AOP states in relation to each point

- It is recommended that the patient should give explicit consent to a record of the examination being taken and kept – not clear if this needs to be in writing.
- AOP: px consent will be implied with regard to making a record of the consultation, and keeping the patient’s records. (when making an appt, it is implied that you will be making record of this, so you don't need to get this in writing)

- Practitioner should obtain px explicit consent to his/her records being passed on to another health professional or a third party
- AOP: if you tell px that you want to refer and px does not object then you have the px’s consent.
(must ask px's consent if giving notes to a 3rd party e.g. employer of a px should get permission in writing)

- Verbal permission from the px is all that is required to pass on dispensing information to another practitioner
- AOP: But clinical information can only be passed on after obtaining written permission from the patient
(if clinical information is being passed to another practise)

16

how should you treat the appointment book and why

- as a record
- Patients can be confused about the practice they visited, whether they kept their appointment etc

17

what does the data protection act recommend about computer records

- Computer records should be backed up regularly
- Ideally daily
- And stored safely away from original records

18

how long does the patient have to make negligence claims

patients have 3 years after they first become aware of the right to make a claim in order to do so.

19

what does the AOP now recommend about record keeping of deceased patients

that we should keep records for 10 years after the death of the patient.

20

what did shah et al find about how many optometrists over recorded and how many under recorded and give examples of each

- Over-recording occurred for 4.4% of clinical “tests” (includes history & symptoms and patient management)
e.g. 8% of optometrists recorded they had looked for Shafer’s sign when they had not performed the test in a patient with symptoms of flashes and floaters
= written down that done it, but did not actually do it

- Under-recording occurred for 17.2% of clinical “tests”
e.g. 3% under-recorded tonometry results in a patient at risk of glaucoma
e.g. 15% under-recorded slit-lamp bio examination of the fundus in a patient with symptoms of flashes and floaters
= might have done it but didn't record it