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You should use your professional judgement to decide whether taking an image or scan is appropriate for the patient, and you must only recommend examinations if these are clinically justified and in the patient’s best interests.14
Whenever an image or scan is taken, you should ensure that the date that it was taken is clear, and that it is assigned to the correct patient. If this information is not embedded in the image or scan itself, you should save it in the appropriate place in the patient record.
You should allow sufficient time to analyse each image or scan. How much time will depend upon the patient’s clinical circumstances, and the complexity of the image or scan. You should compare the image or scan with previous images or scans, if they are available, to decide whether there is a clinically significant change in the patient’s ocular structures.
You should record:
  1. which image or scans have been taken, and which structures examined
  2. whether you have compared the findings with previous image or scan, and if so which image or scan you have compared the current image or scan with
  3. whether there has been any change
  4. any abnormal findings, or findings of note, such as an unusual fundus appearance.