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What to record

You must keep full and accurate records, made at the time of the examination, or as soon as possible afterwards8. These would normally include:
  1. telephone or email contact with the patient by optometrists and other staff
  2. patient visits to the practice
  3. details of your examination
  4. when a patient has declined a test. If the patient refuses or withdraws their consent you should record the reason the patient has given, and the advice you have given9 
  5. management of the patient.
You may use abbreviations. However, you should use only common abbreviations. There is a list at Annex 2, but this is not definitive.
Your records must include:10
  1. the date of the consultation
  2. the patient’s personal details. This should normally include the patient's:
    • full name
    • date of birth
    • address
    • other contact details
  3. the reason for the visit and any presenting condition. This should normally include the patient’s:
    • symptoms, description and duration
    • if relevant, history of ocular and general health
    • current general health
    • medication
    • family history of ocular and general health
    • visual needs in terms of occupation, recreation or general activities
    • whether the patient drives, with or without prescription
    • previous optical prescription and date of last eye examination or sight test. This can be approximate, if the exact date is not known
  4. clinical examination. For a routine eye examination this should normally include the patient’s:
    • unaided vision and/or vision with habitual prescription R and L, as relevant
    • ocular muscle balance and method, at least cover test, for distance and near correction with habitual prescription, and/or without, if appropriate
    • external examination using a slit lamp
    • internal examination, with or without dilation. If dilation is used, record which drug and concentration, batch number and expiry date:
      • media status + diagram of opacities if appropriate
      • Optic disc assessment R and L including C/D ratio, NRR assessment and any unusual features
      • A/V ratio R and L and any unusual vessel features, for example nipping, irregular calibre
      • macular status R and L
      • diagram of any fundal lesions
      • results of peripheral retina examination
      • you may also need to include the following items, as appropriate:
        • near point of convergence
        • ocular motility assessment
        • pupil reactions
        • objective refraction results (autorefractor and/or retinoscopy)
        • fundal or other imaging
        • IOP readings and method and time of readings
        • visual field examination, type of field screener used, which programme, what brightness, if not automatic, and what correction worn by the patient. A printout of any abnormal results
        • results of any repeated tests to eliminate spurious results
    • refraction, if conducted:
      • subjective refraction, if cycloplegic used, what drug and concentration, batch number and expiry date
      • distance VAs R and L
      • reading addition with reading VA binocularly or individually if appropriate
      • ocular muscle balance and method, at least cover test, for distance and near with new prescription if appropriate, for example significant change
      • fixation disparity if appropriate, for example, if the patient has symptoms or shows a deviation on cover test 
      • prescription given for each task, for example, driving, visual display unit (VDU) and any associated reasons, for example, to reduce headaches, to try and improve ocular muscle balance
      • accommodation, if appropriate
  5. contact lens examination, if appropriate. This would normally include the current lens specification, prescription and care regime
  6. conclusions:
    • details of discussions with the patient, including options and oral and written advice given, for example, to drive with spectacles
    • any change in patient management
    • details of any referral. You should keep a copy of the referral letter with the patient record
    • details of any notification sent to the GP and a copy of the letter
    • details of any written information given to the patient, such as patient information leaflets, and
    • recall date and reason if early recall suggested
  7. details of all those involved in the optical consultation, including name and signature, or other identification of author.12
You should use your professional judgement to decide how and when to record consent. This would be based on proportionality, risk, the patient’s needs and circumstances and the type of treatment or care.13 See section on Consent.
You should record relevant negative as well as positive findings.