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Clinical Record Audit

Clinical Record Audit (CRA) SOP


What is a Clinical Record Audit?


This is an assessment of the information that Optometrists collect as part of their clinical appointments. It is not an assessment of the clinical capability of an Optometrist (although it may highlight inconsistencies which may prompt further support and development).


The Hakim Group CRA process has been designed from the audits on Quality in Optometry and GOS auditing tools, along with guidance from the AOP and College of Optometrists.


Why do we do them?


Legal and contractual reasons – a GOS contractor needs to ensure that full and contemporaneous records are maintained by all their performers. The GOC in its Standards for Optical Businesses also sets out that audit is an essential part of safe practice, which means that businesses must have a system in place which allows audit, reflection and sharing of good practice. Patient protection – we are all here because we want to ensure our patients are well looked after, and as Hakim Group practices we aim to practice to the highest standards. A good quality record allows another practitioner to easily analyse what conversations and tests took place at a consultation and can follow on with ease. Practitioner and practice protection – in the event of a patient complaint, our records are our defence (and if not completed fully, can be our downfall).

When


This should be completed between 1st October to 30th November, annually for every employed and locum Optometrist that has provided services in the 12 months prior.

A new audit should be completed after 4 to 6 weeks for Optometrists whose overall score is scored red and allow them to integrate improvements into their day-to-day practice.


New practitioners should be audited within 3 months of their start date (which will allow them to adapt to new practice processes and IT systems).


How


The audit is on an Excel spreadsheet, which will be available to download from Help Hub and for Scottish Practices from 7th October. We will send a separate notification once this has gone live.


Optometrists or trained Dispensing Opticians should complete the audit on each Optometrist that has worked in the practice in the 12 months prior. If you work in a practice as a sole Optometrist, then an employed CLO/DO can complete the audit. If you do not have an employed CLO/DO then contact the Compliance Manager to support. Employed Optometrists should not complete their employers/Shark’s Clinical Record Audit. Self-audits are not permitted. The records can be chosen at random by picking a random day or days to obtain the 10 patient’s records required. You should aim to pick a mix of age groups to audit. Score each section with a 1 (information present) or 0 (information absent), which will contribute to an overall score for each Optometrist. The items to be assessed are split into two groups: essential and enhanced.

Essential items are seen as a critical part of the eye examination and as such carry a higher-weighted contribution to the overall score Enhanced items provide thorough quantitative and qualitative information which supports any investigation and advice given to the patient and gives more data for future comparisons.


Feedback


Feedback is an essential part of the Clinical Record Audit process. Completing an audit is just 50% of the process, perpetual clinical improvement comes from having a good conversation about what went well and where opportunities to improve exist. The auditor should ensure they have sufficient time planned to have this conversation with the Optometrist being audited.


When


Time should be set aside to discuss the audit results in person using the copy of the audit. The associated feedback form should be prepared after the audit is completed to include positive feedback as well as development needs. A discussion of how improvements can be integrated into the Optometrists routine, along with any training or support required should be recorded, and a date of the next audit agreed.

How


Feedback forms are found on HelpHub CLICK HERE. Once feedback is completed, upload the form and audit spreadsheet onto EcoOnline and input the audit score. Ensure both Optometrist and auditor sign the feedback form.


Note audits are to support continuous development of the Optometrist. The audit should be used as a coaching tool to help improve record keeping standards and patient care.


Training


To support the completion of the Clinical Record Card Audit, a training module has been produced and is available to complete through the HG Academy. Please access this on the Academy through Learning & Development > HG Operations toolkit



References


GOC Standards of Practice for Optometrists and Dispensing Opticians CLICK HERE

GOC Standards for Optical Businesses CLICK HERE

College of Optometrists clinical guidance on patient records CLICK HERE

AOP advice and guidelines on safe-practice-record keeping CLICK HERE



CRA SOP FINAL VERSION 1
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