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Concerns about misplaced records

U2.1.17 Concerns about misplaced records

The query this month is a subject that everyone will relate to: lost records.

Our member’s query was a little more complicated. He is a locum contact lens optician (CLO) for a small group of opticians and they have a problem with retaining staff.

Optical assistants or receptionists seem to come and go with alarming frequency, resulting in very poor support for the locum CLO who has worked in the practice for many years. Consequently, the number of records that are misplaced is becoming a real problem. What makes it worse is the rather cavalier attitude of the practice manager, who simply shrugs and says: “What can I do?”

Our member had very real concerns that he might be held responsible by the General Optical Council for failing to maintain proper records when the (paper) records were lost so frequently. He tries to remember as much as possible from previous appointments, but one day he fears he will forget something clinically vital.

I did feel for this member. We have all misplaced records but a serious hunt usually results in them surfacing in a most unlikely place. If a record is indeed lost forever, a trawl through past invoices and referral letters make a duplicate copy a reasonable starting point. What lenses were supplied, when they were supplied and advice given, can all be noted and carefully marked that the original was lost and the resulting records were compiled from memory and other documentation held by the practice. It is a long and tedious task but must be done.

An audit would show the problem but also the effort gone into replacing them, which in itself would reassure anyone checking that the patient’s welfare was being cared for. This particular query was a little more serious when poorly trained staff were careless in their duty of filing and the manager was making no effort to correct the situation.

It would be a shame if the locum CLO was so disillusioned by the situation that he felt compelled to leave the practice, although that is the ultimate sanction he has. It does little to benefit the patients in his care though, when a new practitioner would have even less information to work with.

I advised that the member wrote formally to the owners of the practice, copying in the manager, explaining the seriousness of the situation and seeking help and support. There might well be no action as a result of the letter but the owner has a responsibility of care as well, especially if the company is a registered body corporate, and should be made aware that their employees are not maintaining standards.

This sort of ‘whistleblowing’ would make our member far from popular within the practice and, indeed, his position may be untenable – but that is a risk he must take if the situation is to be rectified and the standards of care maintained.