How well does record abstraction quantify the content of optometric eye examinations in the UK?

A recent review found standardised patient (SP) methodology to be the gold standard method for evaluating clinical care. We compared the clinical records describing the content of optometric eye examinations with the actual content, as revealed by SPs.

We recruited 111 community optometrists in the South East of the UK who consented to be visited by unannounced actors for an eye examination. The actors received extensive training to enable accurate reporting of the content of the eye examinations, via an audio recording and a checklist completed for each clinical encounter. Each participating optometrist was visited by three standardised patients. Upon completion of the standardised patient visits, copies of the clinical records were requested. Using the SP findings as the gold standard, the information gathered from the clinical record was classified for each quality criterion as true positive (reported by SP and documented on the record card), false negative (reported by SP but not documented on the record card), false positive (not reported by SP but recorded on the record card) and true negative (not reported by SP and not recorded on the record card).

Compared to the gold standard, false positives were identified during record abstraction in 4% of cases and false negatives in 18% of cases. For symptoms and history, the proportion of false negatives ranged from 15% to 25% and 3 to 4% for false positives. The proportion of false negatives for tests performed during the eye examinations ranged from 12% to 22% and false positives ranged from 2% to 6%. Optometrists give patients more verbal advice than is indicated in their records (false negatives, 11-19%). Five to 15% of practitioners recorded patient management and advice that was not reported by the SPs.

Our findings regarding optometric consultation mirror the findings in other healthcare disciplines: clinical records are an imperfect representation of the content of a clinical consultation. Clinical records are subject to a recording bias leading to both under- and over-estimation of the care provided due to the presence of false negatives and false positives. This study has important implications for clinico-legal cases, where clinical records are a key item of evidence; and our findings indicate that accurate record-keeping should be a priority for optometric continuing education.