Documentation and Continuity of Care

Accurate documentation is central to patient - centred optometry. Recording concerns in patients' own words preserves their voice beyond the consultation and communicates clearly with colleagues.^[1][5][3]

Structured notes support continuity.

^[4]

Capturing the patient's voice

Patients describe problems in ways that may not match clinical terminology. Verbatim phrases preserve meaning and avoid misinterpretation - "letters jump around on the page" is not the same as "blur."^[6][5]

Retaining original phrasing keeps subtlety intact when translating into clinical language.^[6]

Linking concerns to clinical findings

Records should connect patient concerns with examination outcomes. Link "glare when driving at night" with lens changes at the slit lamp, or "difficulty reading small print" with presbyopic change.^[1][3]

Aligning subjective and objective information reflects both perspectives.^[1]

Supporting continuity through referrals

When referring, carry the patient's voice forward. Include direct quotations or summarised concerns - e.g., "patient reports flashes several times per week" - to provide context even if findings are unremarkable.^[8][1]

Best practice in clinical record keeping

Effective listening is reinforced by:

• Documenting verbatim descriptions alongside clinical interpretations.^[5][6]
• Highlighting the patient's main priority (comfort, cosmetic appearance, visual performance).^[3][7]
• Recording options, risks, preferences, and the rationale for the agreed plan.^[3][1]

These practices improve accuracy, support multidisciplinary communication, and safeguard the patient's central role in ongoing care.^[4][8]

References (numbered in text) Why we include references

1. Patient records. The College of Optometrists. Find (opens in a new tab)
2. Standards of practice for optometrists and dispensing opticians — 8. Maintain adequate patient records. General Optical Council. Find (opens in a new tab)
3. Good medical practice — General Medical Council. Find (opens in a new tab)
4. Records Management Code of Practice. NHS England (Document first published 2017; updated 2025). Find (opens in a new tab)
5. Guidelines for Patient-Centered Documentation in the Era of Open Notes: Qualitative Study. Anita Vanka; Katherine T Johnston; Tom Delbanco; Catherine M DesRoches; Annalays Garcia; Liz Salmi; Charlotte Blease. JMIR Medical Education, 2025. Find (opens in a new tab)
6. Quoted text in the mental healthcare electronic record: an analysis of the distribution and content of single-word quotations. Lasantha Jayasinghe; Sumithra Velupillai; Robert Stewart. BMJ Open, 2021. Find (opens in a new tab)
7. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. NICE Clinical Guideline CG138 (Published 2012; last updated 2021). Find (opens in a new tab)
8. Referrals from community optometrists in England and their replies: A mixed methods study. Krystynne Harvey; David F Edgar; Rishi Agarwal; Martin J Benwell; Bruce JW Evans. Ophthalmic and Physiological Optics, 2022. Find (opens in a new tab)