Maintaining accurate and detailed patient records is critical for optometrists because it can help them both provide the best possible patient care and it can protect them from possible professional complaints. Some optometrists try to get by with minimal patient charting, but they are taking a significant professional risk. It is always better to be safe and document as much as possible.
The California State Board of Optometry actively enforces its rules, and it can take disciplinary action against optometrists for reasons such as incompetence or gross negligence. Patients can file a complaint with the Board if they believe that they received poor care. For example, they may claim that an optometrist failed to diagnose a critical condition with their eyes.
Your first line of defense is records of the actual care that you provided to the patient to show that it met professional standards. The charts will also include patient communication and intake forms that will show whether the patient was complaining of any conditions with their eyes. These are contemporaneous records that both help an optometrist provide care and document what they saw and did at the time.
Patient charts also help an optometrist provide effective care at the time. An optometrist has a better idea of the patient’s medical history and conditions that can impact their eyes. The optometrist can review these records before treating the patient, so they know what to look for and what questions to ask. Further, the patient can then have their own records of their care that can help them get third-party reimbursement for their treatment, and they can take records with them if they switch providers.
Some optometrists may hesitate to keep detailed patient charts for a number of reasons. Beyond the cost and effort, some may be afraid of violating HIPAA. Others may think that they can put together the patient records at the time that they are needed. There is no substitute for investing time and money in a detailed charting system. Patient charts cannot be assembled retroactively if an optometrist is ever questioned. Doctors should never count on their own memory to fill in the details years in the future. They see too many patients. Besides, the Board may look for proof that the patient charts are from the time of treatment to give them relevant weight in a disciplinary proceeding.
As an optometrist, you may find that there is a time when you need to answer allegations about the quality of care that you provided or other allegations of professional misconduct. The Board can take away your ability to earn a living if the allegations are serious enough. You should never try to handle matters alone if you receive notice from the Board that you are being investigated. You should always contact an optometrist license defense attorney to deal with any allegations against you.