7 Maintain adequate patient records

  1. Maintain clear, legible and contemporaneous patient records which are accessible for all those involved in the patient’s care.
  2. 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. The treatment, referral or advice you provided, including any drugs or optical device prescribed or a copy of the 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. This includes details of your supervisor including name and GOC registration number.