Standards of practice for optometrists and dispensing opticians

8.1 Maintain clear, legible and contemporaneous patient records which are accessible for all those involved in the patient’s care.

8.2 As a minimum, record the following information:

• 8.2.1 The date of the consultation.
• 8.2.2 Your patient’s personal details.
• 8.2.3 The reason for the consultation and any presenting condition.
• 8.2.4 The details and findings of any assessment or examination conducted.
• 8.2.5 Details of any treatment, referral or advice you provided, including any drugs or appliance prescribed or a copy of a referral letter.
• 8.2.6 Consent obtained for any examination or treatment.
• 8.2.7 Details of all those involved in the optical consultation, including name and signature, or other identification of the author.