Documenting Supervision

Records must show who supervised what, how supervision occurred, and what advice was given. This creates an auditable trail linking delegation to a registrant's oversight and demonstrates compliance with legal requirements.^[1][3][4]

What to record every time supervision occurs

• Supervisor identity and level: name, registration number if relevant, direct/indirect/remote, and location.^[2][3]
• Task and context: what was delegated, to whom, competence status, and any escalation triggers observed.^[2][1]
• Advice and outcome: key points, decisions made, safety-netting, and the patient's understanding; for remote advice, include mode (phone/video) and timestamps.^[3][5]

Recording supervisee details

Patient records should show not only who supervised but also who carried out the delegated task. This includes assistants, trainees, or students, with their role or training status made clear. Recording both parties creates an auditable link between supervision and performance, showing that the task was delegated appropriately and overseen lawfully.

Example notation:
“Dispense for 10-year-old performed by trainee assistant Patel (competence signed off for measurements) under direct supervision of DO Smith GOC ####; adjustments reviewed; parent counselled; follow-up 4 weeks.”

This ensures accountability is transparent, supports safe delegation, and meets the GOC requirement to record details of those being supervised.^[9]

Practical notation examples

Use concise phrases that bind the event to accountability: "Child dispense performed under direct supervision: DO Smith GOC #### observed PDs/fit; parent counselled on wear/care; review 4 weeks." For remote triage: "Phone advice 14:35-optom Jones: cease CL wear, PFAT QID, review tomorrow under direct supervision; patient understands red flags; texted written advice."^[3][2]

Where supervision is absent for restricted tasks, record refusal and the alternative arrangements offered.^[1][2]

References (numbered in text) Why we include references

1. 9. Ensure that supervision is undertaken appropriately and complies with the law — General Optical Council Find (opens in a new tab)
2. Working with colleagues — The College of Optometrists Find (opens in a new tab)
3. Recording decisions — General Medical Council Find (opens in a new tab)
4. Records management: code of practice for health and social care — Department of Health and Social Care Find (opens in a new tab)
5. Generic medical record-keeping standards — Royal College of Physicians Find (opens in a new tab)