Litigation

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LitigationRecord Keeping

• Presentation
• National Optometric Conference
• by Fiona Mitchell
• Head of Legal Services
• October 2006

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Litigation and Record Keeping

• Record keeping
• Why do we keep records?
• Patient benefit
• Monitor trends
• DEFENCE OF OPTOMETRIST
• What records do we keep?

EVERYTHING
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Litigation and Record Keeping

• Attacks
• Px complaint
• GOC
• Solicitors
• Health Authority
• OCCS
• Health Ombudsman

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Litigation and Record Keeping

• Current GOC Trends

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Defending the Optometrist

• Interrelation of Complaints
• Px Complaint
• Solicitors GOC OCCS
  PCOs
• letter

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Defending the Optometrist

• PCOs
  GOC
• PCO Tribunal NHS (fraud)
  GOC
• Local
• resolution
  Crown Court
• HealthcareCommission
• FHSAA
  GOC

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Litigation Record Keeping

• What records do we keep?
• Patient information
• Clinical
• Dispensing
• Computerised or on paper?
• Content remains the same

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Litigation Record Keeping

• Patient information
• Outer envelope
• Contact details
• Address including postcode
• Telephone number daytime (work/home)
• Other? Mobile? e-mail
• Optometrist identifier
• Driving licence
• Doctors name and address
• Reminder -

VITAL
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Litigation Record Keeping

• Clinical record
• Patient information (continued)
• Family history
• Ocular history
• Health
• Medication
• History
• Symptoms

MAKE ENTRIES IN EVERY CASE
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Litigation Record Keeping
Clinical record Examination Observations right
and left
Internal Media Vessels Discs Macula Periphery

• External - structures
• Ocular motor
• Motility
• Pupils
• NPC

Note ? ? nad ?
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Litigation Record Keeping

• Clinical record
• Examination (continued)
• Intra-ocular pressure
• Time of measurement
• Pressures in each eye
• Method of test
• Visual Fields
• Type of test
• Findings

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Litigation Record Keeping
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Litigation Record Keeping

• Clinical record
• Refraction
• Vision unaided
• Record the prescription found
• Visual acuity
• Record prescription issued

NOTE ADVICE AND RECOMMENDATIONS
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Litigation Record Keeping

• Clinical record
• Contact lenses
• Initial Appointment/New patient
• Separate CL record from spectacles record
• Note when patient last had a sight test
• All appropriate information as for spectacles
• At the end of fitting
• - Give the Specfication
• - Written instruction on use and care of lenses

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Litigation Record Keeping

• Clinical record
• Contact lenses
• Continuing care appointments
• General history symptoms since last visit
• wearing time hours not days!
• Patients comments
• VA with CLs
• Over-refraction
• VAs
• Detailed examination of anterior eye with
  without CLs

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Litigation Record Keeping

• Clinical record
• Contact lenses
• Px compliance
• Conclusions advice actions
• Date of next appointment

Note if they do not attend
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Litigation and Record keeping

• Supply of Contact lenses
• Supplier is now responsible for aftercare basic
• advice to be given to the patient on the
  following
• the need for routine continuing contact lens care
  
• contact numbers/addresses for emergency care.
• Aftercare is limited to this type of direction
  but
• should be given to the patient in writing for the
• protection of the supplier and NOTED on records

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Litigation Record Keeping

• Dispensing record
• Frame
• Facial measurements
• Lenses
• Sign acknowledgement form

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Litigation and Record Keeping
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Litigation Record Keeping

• Data Protection Act 1998
• Patients consent
• Taking records
• Keeping records
• Passing records on to third party
• Consent at start of examination
• Note on record
• need not be written consent (currently)
• This is not the same as patient confidentiality

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Litigation Record Keeping

• Access to medical records
• (Data Protection Act 1998)
• Pxs are entitled to
• Explanation of original records
• Copies of all the records

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Litigation Record Keeping

• How long do we keep records
• NHS terms of service 7 years
• Recommendation
• -Adults 10-12 years dead or alive !
• -Children until they reach the age of 25years
• Limitation period 3yrs from the point of
  realising a negligent act has occurred

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Litigation Record Keeping

• Who owns the records?
• Business
• Optometrist needs access to records
• Consider your position if you are a locum or
  employed and change jobs

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Litigation and Record Keeping
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Litigation and Record Keeping

• Record Keeping Tips
• You should keep full records of the patients
  details, clinical details and dispensing details
• The records should be clearly legible
• The optometrist responsible for the examination
  should be identifiable from the record car
• If you have not noted down the results of a test,
  it is assumed you have not carried it out

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Litigation and Record Keeping

• It is no longer considered acceptable practice to
  use tick marks or the abbreviation NAD
• Note of all advice given to the patient and any
  subsequent action, such as referral
• Whether you record these details on paper or
  electronically, the information should be the
  same
• When you leave the employment ensure you have
  access to the records

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Litigation and Record Keeping

• There is a strong correlation between poor
  records and no defence
• We have 795 active cases
• Litigation is here to stay
• Best defence is a full record

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Litigation Record Keeping

• What to do 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
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Litigation and Record Keeping