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Compliance and regulation
Record keeping

Updates

Background

Whether you are an individual, manager or practice owner, good record keeping should be a priority. This is because making and maintaining full and accurate patient records is an essential part of good clinical care. Accurate records also play a vital role in defending clinical negligence claims and other complaints.

We recommend you read the College of Optometrists detailed guidance on patient records. This covers why you should keep records, what to record, how long to store information and more.

If you provide General Ophthalmic Services (GOS) in Scotland, record-keeping requirements are also set out in Regulations [1]. PCA(O)(2019) 02 most recently sets out that you should follow professional guidance and "must keep appropriate clinical records as relevant to any eye examination conducted" and the record should include:

  • a record of any relevant history and symptoms, and relevant medical, family and ocular history. CHI number if available
  • all relevant clinical details and
  • a digital image of the retina when taken.

Other advice and support

You might also find the GMC guidance on keeping records helpful.

Health records also include sensitive personal data, so you must make sure you comply with the Data Protection Act 2018 and are registered with the ICO.

Updates

Originally published: September 2018

Reviewed: January 2020

Next review date: January 2021

Info: Amendments made to original resource, including adding a link to GMC guidance and cross-referencing data protection guidance and specific guidance for GOS providers in Scotland.