The clinical record is extremely important for the patient because it establishes baseline data and can be used to monitor any change over time. It is used for establishing the patient’s ocular and general history, as well as defining problems and any therapy and advice given to the patient in the past. It can also be used as a primary tool in legal matters dealing with professional liability.
In a clinical setting, the record is important in the control of patient care, in that the same optometric student and doctor may not care for the patient each time. This necessitates that the history, date, diagnosis, treatment, advice and plan of the patient be accurately and clearly conveyed to the new intern and doctor. “Good record keeping leads to good patient care.”
- For the majority of patient care, the electronic health record (EHR) contains all of the examination notes on each patient evaluation. At minimum,visual acuities, findings from the evaluation the assessment (as well as diagnostic codes) and plan should be recorded.
- A new examination record form should be generated with each evaluation. The record should be recorded so that a different optometric student intern or doctor could look at the record and quickly see the diagnosis, treatment, advice and disposition. Any suggested or scheduled subsequent visits should be indicated with procedures to be done on the return.
It is expected that
- Each patient encounter (Clinic visit or phone conversation) must be documented and pertinent data and advice recorded in the EHR.
- The attending O.D. or M.D. MUST sign each record. This rule is not only for controlling proper patient care, but also for legal reasons.
- Student interns are also legally responsible for all their patients as outlined in the Business and Professional Code, Section 3042.5. This legal responsibility extends beyond graduation because of the statute of limitations.
- All information gathered on patients will be used in a professional manner. The confidentiality and the protection of our patients’ data should be treated with the highest regard at all times. State law and professional ethics require that patient findings or other health or personal information be used appropriately and for the purpose for which it was collected. Misuse of this information is illegal. All student interns, faculty and staff are required to review HIPAA rules and sign an Oath of Confidentiality.
The record system will work smoothly if the student intern clinicians abide by the following guidelines
- Every patient encounter must be entered in the EHR. This is without exception.
- Each patient contact (visit, phone call, e-mail, fax, etc.) must be recorded in the EHR.
- NO RECORDS LEAVE THE CLINIC. Ignoring these regulations may be grounds for immediate dismissal.
- Examination fees are to be paid at the time of the exam.
- If ophthalmic materials are being ordered, fees for ophthalmic materials must be paid prior to their order. In addition, the prescription order record must also be completed for each ophthalmic order.
- Staff review clinic records daily and in the case that there is any incorrect or missing information, the instructor is notified to correct the error or omission.