Exam Pass Notes

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Core memory spine

• Check identity: confirm the correct patient before opening, entering, uploading, printing or sharing records.
• Enter facts: record what happened, who did it, when it happened and any required follow-up.
• Measure carefully: record only measurements you are trained and authorised to take.
• Protect privacy: use need-to-know access, share the minimum necessary information and use approved channels.
• Hand over: give the receiving colleague the clinical meaning, uncertainties, quality issues and any patient questions.
• Correct or escalate: report wrong records, measurement errors, correction needs and disclosure concerns promptly.

Records and identity

• Entries by support staff can affect clinical care, dispensing, orders, referrals, complaints and continuity of care.
• Wrong-record risk increases with similar names, duplicate profiles, family members, changed contact details, companions present and linked devices.
• Before saving, confirm the patient, date, data source, task and destination system.
• Provide enough context so another clinician can understand the entry without guessing.

Measurements and outputs

• Record measurements with correct labels, units, frame context, the method where relevant, the author and any uncertainty.
• PD is a dispensing measurement used to support spectacle supply; record it only if it is within your training and local procedure.
• Attach images, prescriptions, lensmeter readings and device outputs to the correct record with the correct date and source.
• Support staff must not interpret scans, pressures, fields, prescriptions or clinical findings unless their role explicitly allows it.

Corrections, privacy and handover

• Do not erase, overwrite, backdate, hide or quietly tidy incorrect entries.
• Preserve the audit trail and follow the local correction procedure.
• Use approved channels for records, prescriptions, measurements, photos and printouts.
• Check authority before sharing information with relatives, companions, online suppliers or other third parties.
• Escalate suspected data breaches, wrong-record incidents, clinical concerns, order errors and issues related to complaints or candour.