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