Computerised and Paper Records

Most practices use electronic health records (EHR), often alongside legacy paper notes or device-specific outputs. EHRs improve standardisation, auditability, and availability, but they introduce digital risks that teams need to manage actively. Paper notes still appear in referrals and scanned archives; the hybrid phase benefits from disciplined processes to maintain a single, reliable patient story.

Using electronic records safely and effectively

• Access and accountability: configure role-based access and session time-outs; ensure user actions are attributable.
• Templates with intent: build templates that encourage key fields (onset/laterality, device/method, consent, safety-netting) while preserving free text for reasoning.
• Controlled data flow: manage device exports (OCT, fields) so patient ID, date/time, laterality, and operator auto-populate; avoid manual renaming that invites error.

EHRs can support clinical decision support (alerts for red flags, overdue recalls), yet "copy-and-paste" may propagate mistakes.

Many teams require active confirmation of measurements and discourage templated assessments that do not reflect today's findings.

Integrating paper records and device outputs

Legacy paper can create gaps if not indexed and scanned with metadata. A practical approach is a same-day scan-and-link process that captures patient ID, encounter date, document type, and clinician. It helps to maintain a register of devices and their data paths and to test backups and restoration routinely. When network outages occur, a downtime proforma with back-entry later plus a timestamped note explaining the delay preserves integrity. For practices within NHS pathways, approved secure email or shared-care platforms are preferred; records should show when and to whom documents were sent. Good governance includes periodic audits of attachment misfiles, access logs, and closed-loop referral acknowledgements.

References (numbered in text) Why we include references

1. 8. Maintain adequate patient records — General Optical Council Find (opens in a new tab)
2. Patient records — The College of Optometrists Find (opens in a new tab)
3. Records Management: code of practice for health and social care — Department of Health and Social Care / NHSX Find (opens in a new tab)
4. Guidance on protecting connected medical devices — NHS England Digital Find (opens in a new tab)
5. Data Security and Protection Toolkit — NHS England Digital Find (opens in a new tab)
6. Guidance for sending secure email (including to patients) — NHS England Digital Find (opens in a new tab)
7. Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings — Monique W M Jaspers; J Am Med Inform Assoc. 2011 Find (opens in a new tab)
8. Safe Practices for Copy and Paste in the EHR. Systematic Review, Recommendations, and Novel Model for Health IT Collaboration — Amy Y Tsou et al.; Appl Clin Inform. 2017 Find (opens in a new tab)