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Documentation

Quality statement

Healthcare professionals involved in the care of a person with COAG, suspected COAG or with OHT have appropriate documentation and records available at each clinical encounter in accordance with NICE guidance.

Quality measure

Structure

Evidence of arrangements to ensure that healthcare professionals involved in a person's care have appropriate documentation available at each clinical encounter in accordance with NICE guidance.

Process

Proportion of people with chronic open angle glaucoma (COAG), suspected COAG or with ocular hypertension (OHT) whose documentation and records are available to healthcare professionals at each clinical encounter.

Numerator - the number of people in the denominator whose documentation and records are available to the healthcare professional(s) present.

Denominator - the number of people with COAG, suspected COAG or with OHT attending a clinic appointment.

Description of what the quality statement means for each audience

Service providers ensure that appropriate documentation and records are available to healthcare professionals involved in a person's care in accordance with NICE guidance.

Healthcare professionals ensure they share all appropriate documentation and records with other healthcare professionals involved in the care of people with COAG, suspected COAG or with OHT, and should also ensure that lack of documentation is reported through clinical governance channels.

Commissioners ensure they commission services that make appropriate documentation and records available at each clinical encounter.

People with glaucoma, suspected glaucoma or with ocular hypertension are seen by healthcare professionals who have access to the person's records, which should include information on test results, past medical problems, current and previous medication details, drug allergies and intolerances.

Source clinical guideline references

NICE clinical guideline 85 recommendation 1.1.5 (key priority for implementation).

Data source

Structure

Local data collection.

Process

Local data collection.

Definitions

NICE clinical guideline 85recommendation 1.1.5 states that appropriate documentation and records include:

  • records of all previous tests and images relevant to COAG and OHT assessment
  • records of past surgical and medical history which could affect management
  • current systemic and topical medication
  • glaucoma medication record
  • drug allergies and intolerances.

This page was last updated: 30 March 2011

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Selected, reliable information for health and social care in one place

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.