Standards for optometrists and dispensing opticians

8. Maintain adequate patient records

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