Optometric Management Tip # 152 - Wednesday, December 15, 2004
Patient Records and Forms
Once a practice settles into a format for patient records, it usually sticks for a long time. And for good
reason Ė familiarity aids efficiency. Itís still not unusual to see offices using the older style patient
record cards, often with the OEP tests printed on them. Of course, optometry has evolved greatly in the
past 20 years, and our diagnostic procedures and recording standards have become much more diverse and
sophisticated Ė and wordy, even with a plethora of medical abbreviations.
Electronic medical records
As optometrists look to revise their records, some are moving to computer software for patient records.
This can come in several forms:
- Integrated practice management systems, which have both office administrative functions and patient
records functions, designed for eye care.
- Stand-alone electronic medical record programs, dedicated to eye care, which function side by side with
existing office management systems. Sometimes the demographic data can be pulled from the office management
- Use of traditional paper forms in the office, but high-speed scanners with document feeders are used to
scan all paper onto a large capacity hard drive, creating a computerized file for each patient. The paper
is then discarded. Any form, photo, letter or invoice can be placed in the electronic file and retrieved
easily. This system causes less disruption to office procedures and is very flexible, but it may not provide
all the organizational features of true medical record programs.
In spite of the great advancements in technology, health care has been slow to adopt electronic records
because it is not always faster than paper and pen, at least not immediately. There is a big learning curve
for doctors and staff and computer software can be less flexible when it comes to jotting down a note or
drawing a picture. For doctors who wish to stay with paper records (for now), here are some ideas that may
make your record keeping more efficient.
- Custom design your own exam forms on 8.5Ē X 11Ē sized paper to allow room to write and to fit in
standard file cabinets.
- Choose sturdy file folders with full tabs to accept labels that are printed with the patientís name from
your practice software system. Use first and second initial stickers to prevent misfiling and
year-of-last-visit stickers so files can be moved to a remote location when they get old.
- Use file folders that have metal clips and punch holes in your exam forms to keep them in chronological
order. Place optical forms on the left side and exam forms on the right. Referral letters (incoming and
outgoing), invoices, test printouts and anything else that comes up can be punched and placed in the file.
- Design your comprehensive exam form with specific places for test results in the order they are
performed, so it can aid technicians as they collect data. Pre-print common words, which can be circled and
use yes/no check boxes in order to reduce writing. Leave blank sections on the form so the paper printout
from automated instruments can be taped in place without covering any writing. Having a place for each
test makes it easier to find the data because itís always in the same spot and nothing gets forgotten, but
youíll still need plenty of blank lines for special tests and writing notes.
- Design a dedicated form that can serve for office visits, follow-ups and contact lens checks
- Use a form with just blank lines for general notes and a column for dates on the left side. This form
stays on top of all others. This one is helpful for phone call notes and other visits that are not
associated with an exam.
- Use a different color paper for each form you use so it can be located easily in the file, and on
storage shelves. But make it light in color, so it will photocopy well.
- If you plan to utilize scribes in your exam room, consider making your exam form on two pages, one for
the technicianís pre-tests and one for the doctorís tests. This allows the doctor to keep the tech page
nearby during the exam, so he or she can refer to the data. The tech takes the blank doctor page and
records data as itís dictated, and completes the diagnosis, plan and prescription sections.
Best wishes for continued success,
Neil B. Gailmard, OD, MBA, FAAO
Chief Optometric Editor, Optometric Management