Patient Records omission

The preferable means of making a referral is to choose the practitioner and arrange the appointment before patients have left the office. This information, along with any other pertinent data relative to the referral, should be noted in the patient record. If a referral letter is written, a copy of the letter should also be retained in the record. Because of the importance of docmnenting referrals, clinicians should establish a fail-safe system of review to ensure that appropriate entries have been made. The omission of this information, if litigation should ensue, unalterably weakens the optometrist s defense. 

It should be noted from the outset that the current systems related to billing are rather weak on outcomes data. In reduced structured data from such sources for analysis of outcomes research, it is not always possible to deduce directly whether the patient died or got better, which are startily different outcomes. All that can then be learned with assurance is that the patient has currently passed beyond the concerns of healthcare insurers. So for this reason alone, aside from other omissions, these data are not a replacement for the digital patient record, but only a good first step and supplement. 

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