During face-to-face visits, your assessor will need to see you doing the following:

• history taking
• communication with the patient
• interpreting and investigating presenting symptoms
• refraction
• assessing binocular status
• assessing the external eye and adnexa
• slit lamp examination
• direct ophthalmoscopy
• indirect ophthalmoscopy
• contact tonometry
• Soft lens fitting.

You must review any patient record evidence you want to be assessed with your supervisor.

Patient records must be original, include patient consent and be contemporaneous (Contemporaneous means the record that was completed at the time of the examination or dispense). 

If you are in the Hospital Eye Service, an original, contemporaneous record is one that is kept in your HES logbook/notebook, and signed by the supervisor at the time of the consultation.

Dispensing patient records must be the complete record and not the printed patient order. A complete dispensing record outlines the patient’s requirements, and the advice and specifics of the device ordered.

Do not alter patient records in any way. 

If your visit happens at a different practice to where the original records are kept, you can present your assessor with copies. Copies will only be accepted if each one is individually signed off by your supervisor as an exact copy. 

All patient records used in remote visits will need to be anonymised. You should present an anonymised patient record in the same way you would present a patient record at a face-to-face visit.

There is no requirement to anonymise records that are shown to your assessor during a face-to-face visit, even if a competency with anonymous patient record as compulsory evidence has been carried forward from visit two.

How to anonymise and present your records

You must not alter the patient record in any way, beyond anonymising. Changes to patient records are considered a form of cheating.

In your place of work, remove:

• the patient name
• address
• date of birth
• GP details
• telephone number
• any other patient identifiable details from the record.

You need to duplicate the record before anonymising. You can either redact records electronically or cross the details out with black ink so that details cannot be seen. 

You must do this while in your place of work. You must never take patient records with identifiable features out of your work premises.

You can record the age and ethnicity of the patient on the record if it is clinically significant.

Once a record has been anonymised, store it electronically so that you can screen share it during your visit.

Your supervisor must then sign a separate declaration confirming that your anonymised patient records have been checked, and appropriately anonymised.

Be prepared to share the record on screen with your assessor during your visit. The record must be clearly visible to the assessor.

The anonymised record should not be sent to the assessor ahead of a visit, or ever held by the assessor.

You must keep a record of the actual patient record from which each anonymised patient record is taken, in case your assessor needs to cross-check it.

Record checking

At visit three, your assessor will check a minimum of three, and not normally more than ten records across the categories of anonymised patient records, reflective accounts and trainee-led case discussions that you used at visits one and two.

We have produced witness testimony templates.

When demonstrating a skill for a witness testimony, the following can be performed on either a patient or your supervisor/other practice staff member:

• 3.1.1 Keratometry
• 4.1.2 Measurement and verification
• 5.1.3 RGP fitting, insertion and removal
• 3.1.8 Assessment of the anterior chamber for signs of ocular inflammation.

These are the skills that you must demonstrate on a real patient:

• 7.1.4 Management of a child under two years of age
• 8.1.7 Management of incommitant deviation.

You must produce a reflective account as evidence for the following skills:

• 1.2.1 Understanding patient expectations
• 1.2.2 Communication with patients who have poor or non-verbal communication
• 1.2.5 Communicates effectively with any other appropriate person involved in the care of the patient
• 2.2.1 Management of patient with additional clinical or social needs
• 2.2.6 Referral
• 4.1.7 Non-tolerance in dispensing.

We have produced a template and guidance for completing reflective accounts.

Reflective accounts are in addition to your reflective portfolio. 

Trainee-based case discussions (TCD) are discussions, led by you, and based on a real record of a patient you have seen.

Trainee-based case discussions are used to assess competencies where patient records alone don’t give enough information on your thought process, decisions and actions (i.e. in relation to investigating symptoms, management-planning and some dispensing elements).

When presenting your record to your assessor, you should cover the following information:

• Age, gender and race (if significant)
• Relevant presenting symptoms and history
• Investigations and findings
• Clinical decision and management
• Advice given to patient.

You must not submit any case information to your assessor before your visit.
 
You must keep a record of the actual patient record on which each trainee-led case discussion was based, in case the assessor needs to cross check it. 

Record checking
At visit three, your assessor will check a minimum of three, and not normally more than ten records across the categories of anonymised patient records, reflective accounts and trainee-led case discussions that you used at visits one and two.