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Clinical Record Keeping in Glaucoma

2 CPD in Australia | 1G in New Zealand | 5 March 2019

By Rajendra Gyawali, Melinda Toomey, Professor Fiona Stapleton and Dr Isabelle Jalbert

Accurate record keeping is an important activity in the process of detecting, monitoring, and managing glaucoma. This article discusses the basic aspects of record keeping, focusing on glaucoma care practice, and provides practical tips on clinical record keeping with glaucoma relevant examples. 

LEARNING OBJECTIVES

1. Appreciate contents of a good clinical record,

2. Understand the role of good clinical record keeping in providing appropriate glaucoma care,

3. Realise the medico-legal requirements of good clinical records within the Australian context,

4. Be able to discern and document important risk factors for glaucoma during case history investigation, and

5. Know how to document important information and investigation results in clinical records for both initial glaucoma assessments and follow ups.

Glaucoma is a progressive optic neuropathy that can result in vision loss and blindness. It is the second leading cause of blindness worldwide with a global prevalence of 3.54 per cent.1 Affecting an estimated 64.3 million people in 2013, this is expected to increase to 76 million in 2020 and to 111.8 million by 2040.2 The Australian National Eye Health Survey estimated a prevalence of 3.4 per cent and 1.6 per cent for non-Indigenous and Indigenous Australians, respectively.3 Of those with glaucoma only 52.4 per cent and 28 per cent of Indigenous and non-Indigenous Australians respectively reported that they knew they had glaucoma.3 Primary open-angle glaucoma (POAG) accounts for nearly 90 per cent of all glaucoma. It is typically an asymptomatic condition that requires access to eye care services in order for a diagnosis to be established, which may partially account for the number of undiagnosed cases. Glaucoma has a significant societal cost, both in direct and indirect costs, with total costs estimated to reach AU4.3 billion dollars for 379,000 affected Australians in 2025.4 Early detection and treatment of glaucoma reduces the risk of vision impairment, as well as lessening the personal and societal economic burdens of the disease.

Both the diagnosis and monitoring of glaucoma require multiple investigations over a longitudinal time frame to identify progressive changes compared to baseline findings. This makes accurate record keeping an important activity in the detection, monitoring, and management of glaucoma. While most eye care practitioners are understandably aware of the importance of good clinical record keeping, reports and news of adverse consequences of inappropriate record keeping are emerging. For example, an Australian eye care practitioner was recently penalised for inappropriate practice based on the Professional Services Review committee’s finding of inadequate recordkeeping.5 With the rising burden of chronic and disabling conditions such as glaucoma, eye care practitioners are constantly challenged in their best practice skills. Clinical record keeping is one essential but often overlooked aspect of such skills.

Clinical Record Keeping: An Integral Component Of Eye Care Services

Terms such as clinical record, medical record, health record, or medical chart are often interchangeably used to describe the systematic documentation of individual patients’ relevant clinical information and care across time in a clinician’s jurisdiction. In a more physical sense, ‘clinical records’ encompass a range of data and information from storage mediums (frequently paper or electronic) containing patient information. The Code of Conduct from Optometry Board of Australia6 (adopted by Optometry Australia7) and the Medical Board of Australia8 (adopted by the Royal Australian and New Zealand College of Ophthalmology, RANZCO9) clearly states that good clinical record keeping is a key responsibility of respective eye care practitioners. Table 1 shows some of the common materials that are encompassed in patient records, based on recommendations from Optometry Australia.7 Although the records may include other forms of information (such as diary records, samples etc), information exchanges such as email and file notes of discussions between eye care practitioners and their medical indemnity insurer or solicitor are typically not stored in the medical record. These documents should be kept as separate medico-legal files.

Table 1. Common inclusions in a clinical record

 

Paper Vs Electronic Records

Although conventional paper based record keeping has been practised for decades, more recently, practices and clinicians have begun using electronic forms. Electronic record keeping systems provide superior storage, better legibility, and ease of access. On the other hand, concerns such as security, interruption in clinical workflow, time consuming data entry, interference with face to face patient care, low quality of information due to the copy-paste function, and template based notes are cited as some of the reasons that prevent the widespread adoption of electronic recording systems in general clinical practices.10,11 The type of recording systems (electronic vs paper records) impact patient care, with electronic record keeping facilitating quality of delivery of several aspects in the clinical care process compared to paper records.12,13 An Australian study measuring the appropriateness of eye care services using patient records indicated better performance of practices using an electronic recording system.14 A wide range of electronic recording systems for eye care practices are becoming available and practitioners need to consider factors such as associated imaging and computerised testing, reporting and outcome analysis needs, documentation and security, cost and organisation demographics among other factors before adopting a certain electronic record system.15,16 Ultimately, the challenge may remain more about how the electronic recording system is used, rather than which one is used: it is the practitioner’s responsibility to maintain good quality of patient records.

Purpose of Record Keeping

Well kept clinical records serve eye care practitioners in several ways. Table 2 summarises the purposes of good clinical record keeping.

Table 2. Reasons for maintaining a good clinical record

 

The Elements Of Good Clinical Records

Clinical records should be contemporaneous, legible, and complete. Figure 1 outlines key principles of good clinical record keeping.28 Some of the common errors in clinical record keeping include illegibility (handwriting, unstandardised abbreviations), inaccuracies (date and time, units, readings), inaccurate patient identification, and language (inappropriate language, opinion mixed with facts, subjective, not objective observations).

In cases where there is no change in care of the patient, writing ‘as above’ to indicate continuity of the previous treatment plan may not be sufficient should the record be subjected to legal scrutiny. The practitioner should record each encounter in concise ‘SOAP’ or equivalent format.29 This ‘subjective’, ‘objective’, ‘assessment’, and ‘plan’ format (SOAP) covers how the patient is feeling and his/her view, the objective examination and assessment of relevant findings, and the management plan, whether to continue or change the treatment. 

Figure 1. 6C’s of good clinical record keeping (adapted from Andrews A and Aubyn B, 2015)28

 

Legal Aspects

Privacy

As eye care practitioners have a responsibility to safeguard sensitive patient information, they need to be cognisant of the Federal, State, and Territory privacy laws. These include the Federal Privacy Act and the Australian Privacy Principles (APP).30,31 APP deal with the life cycle of personal information, from collection, use, disclosure, and security, through to its access and correction. In particular, APP 1 requires practices to have in place an up to date Privacy Policy about how their patients’ personal information is managed. Additionally, APP 1 also requires practices to take reasonable steps in implementing procedures and systems that enable a practice to comply with APP, and to deal with enquiries or complaints about the practice’s compliance with APP.

Complaints about the breach of privacy principles by private practices (private sector organisations) are investigated by the Office of the Australian Information Commissioner. An eye care practitioner or a practice must contact their indemnity insurer in the event of a complaint related to privacy.  

Disposal Of The Records

Eye care practices or organisations are responsible for taking reasonable steps to destroy or de-identify personal information contained in patient records if the organisation no longer needs it for any authorised purpose, although no specific timeframe is stipulated for maintaining records. Legal requirements of individual states or territories provide guidance on the required length and format of retention of records by organisations. For example, in New South Wales, an adult patient record must be maintained for at least seven years from the date the patient was last provided medical services or treatment, whereas this is up to 10 years in Queensland. For children, in New South Wales the record must be kept until the patient attains or has attained the age of 25 years. In Queensland, a child patient record must be retained for 10 years from the patient attaining 18 years of age, and 10 years after the last patient service provision or medico-legal action.7

Paper records must be destroyed using shredding, pulping, or incineration to maintain confidentiality. Electronic data should be deleted along with any backup data, and special care should be taken to ensure that all traces are removed properly (for example overwriting before deleting).

Protect Yourself

Record keeping is likely to play a key role when a complaint is made, a legal action commences, or a prosecution is initiated against a practice or practitioner. However, practitioners often under-record tests performed, history obtained, management advice offered, and appropriate clinical reasoning for the care provided, due to time constraints.32 The tendency is to interpret an absence of a record as meaning that there was no activity or interaction. Although this is not an inexorable rule, a witness will be in a much stronger position if there is a comprehensive record of evidence.33 A good clinical record helps explain any misconceptions about the care given and might sometimes convince or reassure the patient or their lawyer that the care was appropriate. On the other hand, a poor clinical record may strengthen the belief that the care was not ideal and contribute to the pursuit of a claim.

Special attention in relation to clinical record keeping must be paid in some high risk circumstances. These circumstances include: first assessment of the patient, new changes in chronic illness, quickly evolving clinical situations with indications of patient/family dissatisfaction (signs of unease and loss of confidence in the way the patient is being cared for), and refusal of care. In cases where the patient refuses the recommended care (for example dilated fundus examination), the practitioner must record the reasons for the refusal and his or her reasons for believing the patient is capable and competent in decision making. Any discussion outlining the risks and benefits of the recommended care, reasonable alternatives, any offers to return for further care, any communications with the family, and relevant details of any consultations or communications with other care professionals should be documented. Referral is another important aspect and it must be made to an appropriate place with an appropriate degree of urgency. Accusation of inappropriate referrals usually arise if avoidable delay is perceivably introduced by the practitioner.26

In summary, good documentation prevents misunderstandings, contributes greatly to a successful defence, improves care and outcome, and may be the ultimate time saver.

Content Of Clinical Records

The actual content of the patient record is guided by several factors including professional regulators’ requirements,6-9 relevant clinical practice guidelines, Medicare Australia, and any requirements for professional indemnity insurance. Optometry Australia’s recommended content for a patient’s clinical record is summarised in Table 3.7 In addition to positive findings, Optometry Australia recommends that all negative and normal findings should be recorded for continuity of care and legal evidence purposes. Outcomes of imaging and computerised tests (eg. visual fields, corneal topography etc) should also be interpreted and documented in the record with results signed and dated by the eye care practitioner to prove that the reports have been sighted and interpreted. Ideally, these documents should be stored with the record (eg. scanned to the electronic record), however if stored in different locations within the practice, (eg. fundus image on retinal camera) then clear cross referencing should occur, such as a note on the electronic or paper record specifying that the results have been reviewed and where the results are stored.

Eye care practitioners need to carefully consider condition specific clinical practice guidelines to incorporate examination and management recommendations. The National Health and Medical Research Council (NHRMC) glaucoma guidelines22 provides eye care practitioners with evidence based guidelines for the screening, prognosis, diagnosis, management, and prevention of glaucoma. This guideline has good methodological rigour and is comparable with other international guidelines.34

Table 3. Information to be documented in patient records. (Adapted from Optometry Australia)7

 

Record Keeping: Glaucoma Context

A pilot study on the appropriateness of glaucoma care in Australia,35 conducted by the School of Optometry and Vision Sciences at the University of New South Wales in 2017, established essential clinical indicators for appropriate glaucoma care and investigated glaucoma care delivery in six optometry practices and one ophthalmology practice. Preliminary findings found that care was appropriately delivered 58 per cent of the time in this sample. The study also highlighted potential gaps in record keeping for glaucoma by Australian practitioners. Practitioners tended to not document the following information during case history: ethnicity, current and past use of steroid, low blood pressure status, and Raynaud’s syndrome status.35 Similarly, clinical assessments that were not consistently documented included pupil reactions, central corneal thickness, anterior chamber angle configuration, and size of optic disc. Although the majority of practitioners followed the recommended guidelines and recorded recall period, there was large variability among the practitioners.35 

A comprehensive initial glaucoma workup should include all the components of a comprehensive initial eye examination, paying attention to specific elements that relate to risk factors, diagnosis, progression, and management of glaucoma. Using the framework of Optometry Australia’s guideline for record keeping, the next section will explore the important elements of a glaucoma workup that should be documented for all patients.

Patient Information

Patient information allows practitioners to determine and clearly document risk factors for glaucoma based on the patient’s age, sex, and ethnicity. Increasing age is a risk factor for both primary open angle glaucoma (POAG)36 and angle closure glaucoma (ACG).37 Sex is also a risk factor for glaucoma, with females being at greater risk of developing ACG37,38 and normal tension glaucoma (NTG).39 Several studies have found that ethnicity is a risk factor for glaucoma with African people more at risk for POAG41,41 and Asians more at risk for ACG. 22,42 

Case History

A detailed case history assists practitioners to identify additional risk factors for glaucoma related to the patient’s past ocular history, family ocular history, and systemic medical history. A history of trauma or eye surgery can be a risk factor for secondary glaucoma, while a family history of glaucoma is a significant risk factor for POAG, ACG, and some types of secondary glaucoma.43,44 Important information that should be routinely documented from systemic medical history in a glaucoma workup includes: history of migraine, diabetic status, hypertension and hypotension status, presence/absence of Raynaud’s phenomenon, current ocular and systemic medication, and current and past use of topical or systemic steroid. Systemic arterial hypertension,45-47 diabetes,48,49 and lower systolic and diastolic blood pressure50 have been implicated as risk factors for POAG. Migraine39,51 and Raynaud’s phenomenon39 have been found to be risk factors for NTG. It is important to document the patient’s current medications due to the effect the medication may have on their glaucoma, such as systemic beta blockers lowering IOP, and potential contraindications and interactions between current medications and glaucoma medications.22 Long term corticosteroid use, administered by any route, is the main cause of drug induced glaucoma.52,53 Importantly, negative findings for these risk factors should also be documented which may be facilitated by the use of structured paper or electronic records.

At follow up glaucoma assessments, eye care practitioners should ensure they investigate and document interval (ie. changes since the last examination), ocular history, interval systemic medical history and if applicable, compliance to treatment and side effects of ocular medication.

Examination Findings

To accurately detect, differentiate, diagnose, and monitor glaucoma patients, a thorough clinical assessment is necessary. Essential tests that should be conducted and findings documented include:

  • Distance visual acuity,
  • Pupil reaction,
  • Intraocular pressure (IOP) – including time taken and instrument used (ideally applanation tonometry should be performed),
  • Central corneal thickness (CCT),
  • Assessment of anterior segment with slit lamp,
  • Peripheral anterior chamber assessment by gonioscopy or van Herrick peripheral anterior chamber depth assessment,
  • Size of optic disc, cup to disc ratio, and pattern of the neuroretinal rim (NRR),
  • Imaging of the optic disc and/or retinal nerve fibre layer and/or fundus photography, and
  • Visual field assessment with standard automated perimetry.

The majority of these were usually well documented by Australian practitioners in the pilot study. Clinical findings that were documented at sub-optimal levels in the pilot study of appropriateness of glaucoma care will be specifically discussed below.35

Pupil Reactions

While POAG is generally bilateral, it can be asymmetrical with different levels of retinal or optic nerve damage between the two eyes resulting in a relative afferent pupil defect.54,55 Pupil reactions should be performed and documented routinely in glaucoma workups.

Central Corneal Thickness

Central corneal thickness (CCT) should be measured and documented in all patients with ocular hypertension as it allows for the accurate interpretation of IOP readings and is a risk factor for developing POAG.56 The Ocular Hypertension Treatment Study57 found there was a greater risk of developing POAG with CCT less than 555µm compared with CCT of 588µm or greater. As CCT is a relatively stable measurement throughout the lifetime of an individual, a baseline evaluation may suffice. However, clinicians need to be aware of factors such as dry eyes, Fuchs endothelial dystrophy, long term contact lens use, and prostaglandin analogue use that influence CCT and may necessitate periodic re-evaluation of CCT as appropriate.58

Peripheral Anterior Chamber Angle Configuration

Assessment of the peripheral anterior chamber angle configuration is important in differentiating between open and closed angle glaucoma, as well as between primary and secondary glaucoma, and thus should be assessed and documented in a glaucoma workup.22 At a minimum, an estimate of whether the angle is open or closed should be performed by van-Herrick, or ideally, it should be directly assessed using gonioscopy. Additionally, gonioscopy will identify secondary causes of IOP elevation, such as angle recession, pigment dispersion, pseudoexfoliation (eg. Sampaolesi’s line), peripheral anterior synechiae, angle neovascularisation, and inflammatory precipitates.59 Gonioscopy needs to be performed regularly (three to six times per year) in patients with angle closure and periodically in those with open angle glaucoma (every one to five years).22

Size of Optic Disc

Prior to cup to disc ratio estimation and neuroretinal rim (NRR) assessment, the size of the optic disc should be established as the size of the optic cup correlates to the optic disc.60 Healthy individuals with a large disc (vertical disc diameter >2.2mm) will have a large cup, while those with a small disc (vertical disc diameter <1.5mm) will have a small cup.61 Hence, a large cup in a large disc may be misinterpreted as glaucomatous, while a mid-size cup in a small disc might be deemed normal when it is glaucomatous (Figure 2). Clinicians can assess optic disc size using the slit lamp and a condensing lens by aligning a vertical slit over the optic disc then adjusting the height of the beam to match the vertical disc diameter. The height of the beam is obtained from the calibrated knob for the beam, and then optic disc size estimated by applying the correction factor in Table 4.

Figure 2. Classification and illustration of optic nerve head disc size. Image source: Thomas R et al62

Table 4. Biomicroscopic measurement of optic disc with condensing lenses. Adapted Ansari-Shahrezaei et al63 and European Glaucoma Society Guidelines64

 

Review Frequency

Regular review is necessary to assess for conversion to, or progression of, glaucoma. Good record keeping requires the documentation of the appropriate review frequencies, depending on risk factor level for developing glaucoma or the severity level of diagnosed glaucoma. Table 5 outlines recommended review frequencies for glaucoma suspects and established glaucoma as suggested by the NHMRC and the Canadian Ophthalmological Society evidence based clinical practice guidelines for glaucoma, respectively.22,58 Factors that place a person at high risk include: family history of glaucoma,43,44 pigment dispersion syndrome (PDS),65 pseudoexfoliation syndrome,66 elevated IOP,57 thin corneas,57 history of steroid use,52,53 and history of major ocular injury.

Table 5. Recommended review period for glaucoma suspects and established glaucoma patients.22,35,58

 

Conclusion

In summary, clinical record keeping plays an integral role in quality eye care delivery including the care of patients with glaucoma. Eye care practitioners must be aware of, and updated with, professional and legal standards of clinical record keeping in their practices. While providing care for glaucoma patients, standard elements in comprehensive eye examination need to be recorded along with specific items such as risk factors, diagnosis, progression, and management of glaucoma. Special attention must also be given to record commonly forgotten elements such as pupil reaction, corneal thickness, anterior chamber angle evaluation, optic nerve disc size, and review frequency. Importantly, for all these investigations, positive, negative, and normal findings should be documented. A well maintained clinical record that is legible, timely, and complete will assist clinicians in dealing with claims, complaints, and legal actions. More importantly, it will improve care for patients with glaucoma.

Practical Record Keeping

  • The history section should include who is providing history, language barrier and need of interpreter, patient’s compliance with recommended care.
  • Absence as well as presence of important risk factors (example: no family history of glaucoma) should be recorded. 
  • The clinician should indicate they have reviewed the results of the examination done by someone else.
  • Relevant negative clinical findings should be noted (eg. neuroretinal rim of symmetrical thickness, no notching)
  • The clinician should document (with rationale) an investigation which is considered but not done/ordered in this encounter. (eg. “Dilated fundus examination (DFE) considered but not performed as the patient is driving. Appointment 2:20pm tomorrow for DFE”).
  • Each entry in the clinical record should be sufficiently detailed (eg. IOP-Goldman Applanation Tonometer, 3:30pm = R 12 mmHg, L 13mmHg).
  • The record should demonstrate that the clinician interpreted and/or acted upon the results from the laboratory, diagnostic imaging and other consultative reports. One approach is to circle, date the day of review, and initial these to indicate they have been seen prior to either action or filing for paper records, and an annotation in electronic records of the findings of the additional investigations.
  • The record should indicate that important results are relayed to patients (eg. “Patient informed about appearance of new areas of reduced sensitivity in superior visual field”).
  • Reasonable differential diagnoses should be listed to convey sense of thought process behind the care provided (eg. some non-glaucomatous neuropathies such as anterior ischemic optic neuropathies, hereditary optic neuropathies, compressive optic neuropathies, and demyelinating optic neuritis may mimic glaucomatous optic nerve changes and visual field loss in patients with non-elevated IOP. Considering and recording these differential diagnoses before reaching a final diagnosis will allow a practitioner to evaluate important risk factors and clinical parameters such as visual acuity, visual field defects respecting vertical midline, pallor of neuroretinal rim, asymmetrical loss of colour vision, and relative afferent pupillary defect. This will also justify a request for any neuroimaging in suspected neurological cases).
  • A direct quote from the patient may be recorded, especially for consent discussions, refusal of care, emotionally charged situations etc.
  • The clinical records must not be tampered with. 
  • Use of a permanent ink is recommended and correction fluid should be avoided (errors should be crossed through with single line and initialled).
  • Appropriate measures should be taken to prevent unauthorised access to electronic records, such as password controlled access or finalising of electronic record that prevents changes at a later date.
  • A good clinical record should limit misunderstanding in collaborative or team care and clearly describe who is responsible for coordinating the care or performing specific care tasks in these collaborative relationships. In a collaborative care team, the patient’s optometrist and ophthalmologist can together develop a written management protocol delineating the treatment goals and the roles and responsibilities of the two practitioners, create a review schedule, communicate clinical information with all parties involved in collaborative care including the patient’s general practitioner to promote an integrated approach, and involve a pharmacist in providing medicines information.
  • The notes should be objective and unemotional. 
  • Any expression of criticism or animosity towards the patient or care team should be avoided.
  • Patients have a right to access their records and any flippant remarks may prompt the patient to initiate a legal action or complaint.
  • Inferences and assumptions should be avoided, but it may be appropriate to suggest alternative investigations, treatment or a professional (team) with justification.



 

Rajendra Gyawali BOptom, MOptom, FAAO is an optometrist trained in Nepal and South Africa. His professional experience includes clinical practice, program coordination, academia and research in Nepal, Maldives, Malawi, Eritrea, Vietnam and Australia. He is currently pursuing his PhD at University of New South Wales focusing on quality of eye care service provision. Mr Gyawali’s research interest includes refractive error and visual impairment, glaucoma, health care delivery, paediatric eye care, eye care in marginalised communities and patient centered eye care.

 

 

Melinda Toomey BAppSci(Optom), MOptom, MBA, GradCertOcTher graduated from Queensland University of Technology and has practiced in the public sector, private practice and in the corporate setting, in roles ranging from clinical, managerial and education. Ms Toomey has completed a post-graduate Master of Optometry, MBA, and Graduate Certificate of Ocular Therapeutics. She has commenced a PhD at UNSW.

 

 

Fiona Stapleton BSc, MCOptom, MSc, PhD, DCLP, GradCertOcTher, FAAO, FCCLSA, FBCLA, FTSE is a Scientia Professor and Head of School at the School of Optometry and Vision Science and Associate Dean (Enterprise) in the Faculty of Science at UNSW Sydney. She is responsible for the teaching of clinical ocular therapeutics in the optometry programme and established the Graduate Certificate in Ocular Therapeutics programme at UNSW. She has published 250 publications, 25 professional articles and one book and has supervised 33 PhD students to completion.

 

 

Dr Isabelle Jalbert OD, PhD, MPH, GradCertOcTher, FAAO is Associate Professor and Deputy Head of School at the School of Optometry and Vision Science and Associate Dean International and Engagement for the Faculty of Science at UNSW Sydney. Dr Jalbert is an optometrist and public health practitioner and teaches anterior eye therapeutics and evidence based optometry. She is recognised internationally as one of the pioneers of evidence based practice for optometry.

 

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' Although conventional paper based record keeping has been practised for decades, more recently, practices and clinicians are choosing electronic forms '