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professional development, and emphasising records not only compromises patient care but
ethical standards and inter-professional also exposes practitioners to legal liabilities and
collaboration, the Act lays a strong foundation disciplinary actions. With NCAHP regulations
for the enhancement of optometric services, just around the corner, state councils will
ultimately leading to improved eye care for the mandate stringent record-keeping standards
Indian population. A crucial aspect of regulation to uphold professional accountability, patient
in any healthcare field is accountability, which safety, and confidentiality. Clinical records will
ensures that practitioners prioritise patient be considered a medico-legal document, as
welfare above all and, more importantly, stay they already are among doctors and dentists,
within their scope of practice. therefore it is important to remember that in
the eyes of the law, if an examination is not
Clinical records serve as a comprehensive documented then it is not done. In the absence
repository of patient information, documenting of meticulous documentation, optometrists
their ocular health history, diagnostic findings, may risk misdiagnosis, treatment errors and
treatment plans, and follow-up care. Beyond allegations of negligence, which can tarnish
facilitating continuity of care, these records aid their professional reputation and result in
in clinical decision-making, enable effective significant financial repercussions. Therefore,
communication among healthcare providers, adherence to legal and ethical guidelines will
and serve as a vital reference point for future be imperative to mitigate risks and uphold the
consultations. Moreover, they play a pivotal role highest standards of professional conduct.
in research, quality improvement initiatives, and
medico-legal proceedings, thereby safeguarding ADVANTAGES OF ELECTRONIC
both patient welfare and professional integrity. MEDICAL RECORDS:
HOW TO WRITE GOOD The advent of Electronic Medical Records
CLINICAL RECORDS: (EMRs) heralds a paradigm shift in healthcare
Crafting accurate and comprehensive clinical delivery, offering increased efficiency, accuracy,
records requires meticulous attention to detail and accessibility. By digitising clinical workflows,
and adherence to standardised protocols. While EMRs streamline administrative tasks and
we await standards to be legally enforced in significantly reduce paperwork. Optometrists
India, the Optometry Council of India’s ‘Best often find themselves staying well beyond
Practice Standards’ guidelines are an excellent practice hours to complete and file their clinical
example for optometric practices to adhere to. records as well as doing additional paperwork
such as preparing patient reports. Adopting
Optometrists should strive for clarity, a good EMR software removes the burden of
accuracy, and completeness in their administration so optometrists and their entire
documentation, ensuring that each entry team can focus on excellent patient care by
is dated, signed, and reflects the relevant enhancing practice efficiency and increasing
aspects of the patient encounter. Structured patient retention.
templates and mnemonic aids can aid in
systematic record-keeping, encompassing ADVANTAGES OF CLOUD-BASED
subjective complaints, objective findings, EMR OVER DESKTOP EMR:
assessment, and management strategies. Cloud-based EMRs confer distinct advantages
Moreover, incorporating narrative descriptions over traditional desktop-based systems,
and appropriate clinical images enriches the chiefly in terms of scalability, accessibility, and
documentation, offering a holistic perspective of data security. Unlike desktop EMRs, which
the patient's ocular health status. are tethered to physical machines and are
LEGAL IMPLICATIONS OF constrained by storage limitations, cloud-based
NON-COMPLIANCE: platforms offer virtually limitless scalability,
accommodating the evolving needs of growing
Failure to maintain comprehensive clinical practices without significant infrastructure
134 | THE INDIAN OPTICIAN | MAR-APR 2024 OPTOMETRY
