Ensuring Continuity of Care

Continuity requires reliable handovers within the practice and complete, actionable communication to external services. ^[4][5] Patients experience continuity when every team member knows the plan, repeats critical advice consistently, and follows up. ^[5][7]

Handover and documentation essentials

Use structured formats (SBAR/SOAPE) to capture the clinical question, key findings with method, and the plan with owner and timeline. ^[6][9] For internal handovers - consulting room to dispensing, or day shift to evening - record what success looks like (e.g., "comfort at computer distance," "review IOP by GAT at 15:00"). ^[4][5]

For external continuity - referral to hospital eye services - attach labelled images, specify urgency with rationale, and note access needs (interpreter, transport). ^[1][3][2]

• Elements to include: Patient priorities; red-flag safety-netting; consent status; device identifiers and quality; follow-up dates; and who will contact whom. ^[7][4][5][1]
• Closing the loop: Track referral acknowledgements; chase outcomes; update internal records and recalls accordingly. ^[5][1]

Operational supports for continuity

Task lists with clear ownership, recall systems with risk-based intervals, and shared dashboards reduce drift. Short end-of-day huddles confirm that urgent actions occurred, and weekly reviews examine any stranded tasks. ^[8][5][4]

Continuity is proven in records when another clinician could take over seamlessly tomorrow without asking for context.^[5][4]

References (numbered in text) Why we include references

1. Referrals — College of Optometrists (College of Optometrists guidance: Working with colleagues / Referrals) Find (opens in a new tab)
2. Accessible Information Standard – implementation guidance — NHS England Find (opens in a new tab)
3. Ophthalmic imaging guidance (update) — The Royal College of Ophthalmologists Find (opens in a new tab)
4. Standards of practice for optometrists and dispensing opticians — General Optical Council Find (opens in a new tab)
5. What to record / Patient records — College of Optometrists (clinical guidance on records and referrals) Find (opens in a new tab)
6. Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review — Lisha Lo; Leahora Rotteau; Kaveh Shojania; BMJ Open Find (opens in a new tab)
7. Optimising GPs’ communication of advice to facilitate patients’ self-care and prompt follow-up when the diagnosis is uncertain: a realist review of ‘safety‑netting’ in primary care — Claire Friedemann Smith; Hannah Lunn; Geoff Wong; Brian D Nicholson; BMJ Quality & Safety Find (opens in a new tab)
8. Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy — Brian J Franklin; Tejal K Gandhi; David W Bates; Nadia Huancahuari; Charles A Morris; Madelyn Pearson; Michelle Beth Bass; Eric Goralnick; BMJ Quality & Safety Find (opens in a new tab)
9. SOAP Notes — Vivek Podder; Valerie Lew; Sassan Ghassemzadeh; StatPearls Find (opens in a new tab)