The College of Optometrists

Patient records

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Sub-sections

Key points

  • Full records are essential to facilitate the clinical management of the patient and continuity of care.
  • You must keep full records to protect yourself in case of complaints.
  • You must keep full, accurate and clear patient records, made at the time of the examination, which provide a history of patient care, including referrals.
  • If you keep electronic records, you or your practice should have an IT disaster recovery plan, regular data backups, adequate training and satisfactory disposal of old systems or equipment.
  • Patient records belong to the practice where they were made.
  • If you work with non-optometrists you must ensure patient records are correctly dealt with when your association ends.
  • You must ensure that confidentiality is maintained during the collection, storage, use and disposal of records.
  • You must comply with the Data Protection Act 1998.
  • Patients have a right to access their records.

Purpose of keeping records

A16
You must keep patient records to:
  1. retain clinical information, including the patient’s history
  2. facilitate the clinical management of the patient and continuity of care
  3. enable another practitioner to take over the care of the patient, and
  4. protect yourself in case of complaints or for reference in a legal situation.
A17
Patient records can provide a reliable statistical basis for research. See section on Research and audit.

What to record

A18
You must keep full and accurate records, made at the time of the examination or as soon as possible afterwards.7 This includes:
  1. telephone 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, and
  5. management of the patient.
A19
You may use abbreviations. However, you should use only common abbreviations. There is a list at Annex 2, but this is not definitive.
A20
Your records should include:
  1. the patient's:
    • full name
    • date of birth
    • address, and
    • other contact details
  2. reason for visit
  3. history and symptoms:
    • 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, and
    • previous optical prescription and date of last eye examination or sight test, approximate, if exact date is not known
  4. clinical examination:
    • unaided vision and/or vision with habitual prescription R and L
    • ocular muscle balance and method, at least cover test, for distance and near with habitual prescription, and/or without, if appropriate
    • external examination, preferably using a slit lamp, and
    • internal examination, with or without dilation; if dilation is used, which drug and concentration, batch number and expiry date:
      • media status + diagram of opacities if appropriate
      • C/D ratio R and L 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, and
      • diagram of any fundal lesions
    • 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
  5. refraction:
    • 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 help headaches, to try and improve ocular muscle balance, and
    • accommodation, if appropriate
  6. negative as well as positive findings
  7. contact lens examination, if appropriate, including the current lens specification, prescription and care regime
  8. actions:
    • 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 also keep a copy of the referral letter with the patient record
    • details of any notification sent to the GP and 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, and
  9. a record of the author, who should be readily identifiable.

References

7 General Optical Council (2010) Code of conduct [accessed 5 Dec 2013]

Electronic record keeping

A21
Some of the guidance in this section relates to the responsibilities of the person in charge of an organisation or practice as well as to your responsibilities as a practitioner within the practice.
A22
If you are setting up a paperless electronic record system, you or your organisation should:
  1. prepare an IT disaster recovery plan first, include provision for regular backups of data which are stored securely and preferably off-site
  2. ensure all members of the team, including locums, can use and access the IT system effectively
  3. ensure that you check the accuracy of any patient records entered on your behalf by an assistant. You remain responsible for the contents of the record
  4. ensure confidentiality is maintained through:
    • access control measures
    • physical security and privacy of systems, and
    • secure communication between systems
  5. ensure every patient record has an audit trail to identify:
    • time/date of each entry
    • author of each entry, and
    • additions, changes or deletions, and
  6. set up or use a properly constructed format which:
    • does not constrain data entry
    • allows free text and clinical codes
    • enables all patient contact and significant health events, such as referrals, to be recorded
    • allows attachments, such as a fundus photograph or referral letter, to be part of the record, and
    • signposts any additional records about the patient which are separate from the main record; however, you should not keep informal patient records.
A23
If you or your practice change the IT system, audit trails may be lost, therefore you should:
  1. create and maintain a verified backup of the clinical data from the old system, and
  2. maintain a means to read this backup.
A24
If systems or hardware are replaced, you or your organisation must ensure that any patient identifiable data is backed up and data on the old computer are destroyed. Deleting information may be insufficient as data can remain accessible on storage media. Hardware, including hard disc drives, should be physically destroyed.
A25
You should not maintain both a paper-based and an electronic system. However, if this is unavoidable, you should avoid parallel systems that contain the same data as they may not be kept up to date.

Ownership of patient records

A26
The practice, rather than the patient or the optometrist, owns the patient records.
A27
All parties involved must ensure the originating practitioner(s) has access to the records in the event of a query, complaint or claim.
A28
If the practice closes, the practice owner should:
  1. arrange to transfer the patient records to another registered practitioner or practice
  2. inform patients this has been done, and
  3. where transfer to another practitioner or practice is not possible, offer the records to the primary care organisation (PCO) or a person nominated by the PCO.
A29
Patients may choose another practice and may give consent for their new practitioner to request relevant clinical information from their records to enable the continuation of their optometric care. You should agree to such requests once you have the patient’s consent.
A30
If you work for, or in association with, non-optometrists you should ensure that your contract states that:
  1. the contractor will keep the records secure and confidential
  2. if the practice changes hands, and optometric care will continue to be provided in that practice, that the records will remain in the practice with responsibility for this being passed to the incoming optometrist, and
  3. if the practice closes, or no optometric care will be provided when your association ends, you have the right to take the optometric records with you. If this happens the contractor should inform the patients.

Confidentiality and privacy

A31
You must respect and protect confidential information when you:8
  1. collect data
  2. store it
  3. use it, including for referrals and research purposes, or
  4. dispose of it.

Data Protection Act 1998

A32
As a practitioner your organisation may be the record holder, but you have responsibilities under the Data Protection Act 1998.9  You should be familiar with the Act. For optometrists key points in the Act mean:
  1. obtaining the patient’s explicit consent to taking and keeping a record of the consultation; the law does not state if this needs to be written consent
  2. keeping accurate patient data
  3. using the data for specific purposes
  4. amending inaccurate data and responding to objections from patients if the use of the data causes harm or distress
  5. keeping the data no longer than necessary. Suggested lengths of time for retaining records are:

     Type of record

    Recommended period of retention

    hospital records 10 years
    children and young people until the patient’s 25th birthday, or 26th if young person was 17 at conclusion of treatment; or 8 years after patient’s death if death occurred before 18th birthday
    general eight years
    patients involved in clinical trials 15 years
  6. keeping the data confidential and secure
  7. enabling patients, or an applicant acting on behalf of a patient, to access their data for the length of time that you keep the records. You must be sure that the applicant has a right to see the data either because they have written authority from the patient or because they have Power of Attorney. Your organisation may charge a fee for a copy of electronic records or paper records. The maximum fee is specified in the regulations and you should check for the most up-to-date fees.10  Access to the record must be given within the time limit set out in the Act
  8. assisting the patient to understand their record by explaining its content and abbreviations
  9. obtaining the patient’s explicit consent if you pass clinical details on to another health professional or third party
  10. obtaining the patient’s explicit consent if you pass information to another practitioner when the eye examination and dispensing are separated
  11. satisfying yourself that there is no further need of the record before destroying it
  12. disposing of any records securely, and
  13. noting that, if you, or your organisation, acquire a patient record the obligations under the Data Protection Act transfer to you as the new owner.
A33
Most organisations that process personal information are required by law to register with the Information Commissioner. Some organisations are exempt from this.11
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