Standards for optometrists and dispensing opticians
8. Maintain adequate patient records
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Maintain clear, legible and contemporaneous patient records which are accessible for all those involved in the patient’s care.
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As a minimum, record the following information:
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The date of the consultation.
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Your patient’s personal details.
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The reason for the consultation and any presenting condition.
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The details and findings of any assessment or examination conducted.
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Details of any treatment, referral or advice you provided, including any drugs or optical device prescribed or a copy of a referral letter.
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Consent obtained for any examination or treatment.
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Details of all those involved in the optical consultation, including name and signature, or other identification of the author.
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