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Key points

  • Full records are essential to facilitate the clinical management of the patient and continuity of care.
  • You must keep full records to protect yourself in case of complaints.
  • You must keep full, accurate and clear patient records, made at the time of the examination, which provide a history of patient care, including referrals.
  • If you keep electronic records, you or your practice should have an IT business continuity plan, good security, regular data backups, adequate training and satisfactory disposal of old systems or equipment.
  • The date that any image was taken should be clear, and the image assigned to the correct patient.
  • You should allow sufficient time to analyse each image.
  • Patient records belong to the practice where they were made.
  • If you work with non-optometrists, you must ensure patient records are correctly dealt with when your association ends.
  • You must ensure that confidentiality is maintained during the collection, storage, use and disposal of records.
  • You must comply with Data Protection Act 2018 and the EU General Data Protection Regulation (GDPR).
  • Patients have a right to access their records.
This Guidance does not change what you must do under the law.