Section ONE Preliminaries

symptoms of adverse effects and how to deal with them; and advice when participating in water sports (see Section 27.4).

Contact lenses for children under sixteen may only be supplied under the direct supervision of a registered practitioner. The same applies to plano tinted contact lenses with the sole function of changing eye colour since they are now designated as medical devices.

3.2 Record cards

The use of record cards with a standard design helps ensure that all procedures are completed and documented. The card is also used as a prompt during the consultation to avoid missing out routine procedures and questions. Photographs or image capture are ideal for recording and monitoring clinical conditions and are superior to simple diagrams. Both methods, however, aid merely descriptive notes (see Section 2.4).

Visits that require full documentation are: Initial, Fitting, Dispensing and Aftercare plus adequate space to record order information and subsequent changes to the lens specification.

3.3 Clinical grading

A simple definition of clinical grading is ‘putting numbers instead of words’. An important aspect of record keeping is to record findings in a reproducible way that can be easily understood by professional colleagues and provide a comparison between patient visits. Various scales are currently in use, while some practitioners have devised their own systems.2 Successful grading needs to be simple, consistent and derived from an understanding of the clinical judgement necessary to discriminate between findings.

Scales are either numeric, usually from 0 to 4, or based on identification symbols. Definitions are helped by photographic or line illustration.

Published grading scales

There are two main published scales currently in use.

The CCLRU grading scale

Devised by the Cornea and Contact Lens Research Unit (CCLRU) in Australia and produced by Johnson & Johnson VisonCare. The grading scales are photographically illustrated and include: corneal staining, depth and extent; conjunctival staining; bulbar and limbal redness; lid redness and roughness; and endothelial polymegathism. The CCLRU scheme uses five grades:

0 = normal

1 = very slight

2 = slight

3 = moderate

4 = severe

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The Efron grading scale for contact lens complications

Devised by Professor Nathan Efron and produced by CooperVision.3

The scale is illustrated with drawings by Tarrant on the basis that the desired level of change can be precisely represented while all other factors are kept constant. Eight complications are included, two from each of the conjunctiva, corneal epithelium, stroma and endothelium. This scheme also uses five grades from 0 to 4:

0 = normal

1 = trace

2 = mild

3 = moderate

4 = severe

The simple 0 to 4 scale can be easily and rapidly recorded on the record card for the most important features of the examination using a mnemonic such as ONIST, where:

O = Oedema

N = Neovascularization

I = Injection

S= Staining

T= Tarsal plate anomalies

This would record trace neovascularization and staining plus slight CLIPC in the right eye together with trace conjunctival injection in the left. The dash would indicate that the lid was not everted on this occasion for which a reason should be recorded. Some sort of pictorial interpretation should always accompany any positive finding for medico-legal reasons.

The Institute of Optometry grading scale

Instead of numbers it is possible to introduce + and − signs to be used with a scheme of consistent abbreviations. In this way, several other features can be graded. Such a system has been devised for use at the Institute of Optometry and includes the following items:

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Section ONE Preliminaries

The combination of scalar grades and measurements in millimetres enables the quantification of most problems. Corneal changes are, in addition, illustrated with scale diagrams. The location, depth and extent can all be recorded with careful drawing.

3.4 Computerization of patient records

Data Protection Act

Practitioners are increasingly using computers for both practice management and storage of patients’ clinical records. It is essential to comply with the provisions of the Data Protection Act in respect of continued registration and the duty to maintain confidentiality of patient information. Safeguards are therefore necessary to prevent unauthorized access to the records.

The registered entry for a practice must contain particulars of the data held and declare the intended purposes of those data. These are numerically classified into some 200 options and the appropriate category numbers must be declared. On average, there are six options that relate purely to patients.

There are eight data protection principles that users must observe:

1.Data should be obtained and processed fairly and lawfully.

2.Data may be held only by registered uses.

3.Data may not be disclosed contrary to their registered purposes.

4.Only the minimum amount of information required should be kept for each patient.

5.Data must be accurate and, where necessary, kept up-to-date.

6.Data should be held for no longer than required and regularly deleted where necessary.

7.Proper security is essential. All reasonable steps should be taken to ensure that there is no accidental loss of data or improper access.

8.Individuals are entitled to know what personal data may be held on them and are entitled to a copy of those data. If appropriate, inaccurate data may need to be corrected or erased.

With certain provisos, computer-generated records are admissible as evidence in a court of law. The system must be tamper-proof and needs to incorporate an audit trail that dates, times and records every change to the files as well as identifying the author.

Compared with written notes, there is a greater risk of accidental loss to computer records, so full back-ups must be taken regularly and stored securely. Patient records should be kept for at least 10 years, so any upgrading of the computer system must allow transference of data. To avoid mistakes, the practitioner must maintain supervision over the input of data, although this is frequently delegated to unqualified personnel.

References

1.Edwards K. How to cover the legal aspects of CL practice. Optician 2002;224(5871):16–18.

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2.Lloyd M. Lies, statistics, and clinical significance. Journal of the British Contact Lens Association 1992;15(2):67–70.

3.Efron N. Contact lens complications: clinical application of grading scales for contact lens complications. Optician 1997;213(5604):26–35.

Further reading

General Optical Council (Contact Lens Qualification etc: Rules), Order of Council 1988. General Optical Council The Contact Lens (Specification) Rules 1989.

College of Optometrists Code of ethics & Guidance for the Profession, 2001.

Association of Optometrists Members’ Handbook. ‘Computerised records’, current issue.

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