Documenting Assessments and Decisions
Clinical records must allow another professional to reconstruct what was done, why it was done, and what the patient understood. [2][7] Good notes protect patients, enable continuity, and provide medico-legal defence. [7] Write contemporaneously, attribute entries, and avoid cloning errors. [2][7]
What every record should contain
- History including functional impact and patient priorities; positive findings and pertinent negatives; test reliability/limitations. [3][2]
- Differential diagnoses, reasoning for chosen tests/treatments, and safety-net instructions. [3][5][7]
- Consent, escalation/referral details with urgency and contact points; copies or summaries provided to the patient. [3][1][5]
Quality and interoperability
Use standard terminology, link images/measurements to the encounter, and make adaptations explicit (communication aids, modified tests) so future results are comparable. [6][4][2] Summaries should highlight the clinical question and current plan upfront for rapid comprehension by colleagues. [7]
Using records to drive quality
Periodically review a sample of notes against a local checklist (history completeness, red-flag screening, referral clarity). [4]
Share de-identified exemplars at peer meetings to harmonise standards. [4]
Where gaps recur, update templates and provide focused training. [4][2]
References (numbered in text)
- Standards of practice for optometrists and dispensing opticians: 7. Conduct appropriate assessments, examinations, treatments and referrals — General Optical Council Find (opens in a new tab)
- Standards of practice for optometrists and dispensing opticians: 8. Maintain adequate patient records — General Optical Council Find (opens in a new tab)
- Patient records — College of Optometrists Find (opens in a new tab)
- Records Management Code of Practice — NHS England (Records Management Code of Practice) Find (opens in a new tab)
- Suspected cancer: recognition and referral (NICE guideline NG12) — National Institute for Health and Care Excellence (Published 23 June 2015; last updated 01 May 2025) Find (opens in a new tab)
- Clinical coding – SNOMED CT — NHS England Find (opens in a new tab)
- Good Medical Practice — General Medical Council Find (opens in a new tab)
References are included to demonstrate that all the content in this course is rigorously evidence-based, and has been prepared using trusted and authoritative sources.
They also serve as starting points for further reading and deeper exploration at your own pace.
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