Reading List

This Reading List supports learning from the course on patient record keeping for UK optical professionals and prioritises current, authoritative UK guidance to apply in daily practice.

Core professional standards and frameworks

• GOC Standard 8: Maintain adequate patient records Core professional expectation for adequate, legible and contemporaneous optical records.
• GOC Standards of Practice Context for record keeping within wider professional duties.
• College of Optometrists: Patient records Practical guidance on what to record, imaging, ownership, confidentiality and electronic records.
• NHS England Records Management Code of Practice National rules on content, retention, disposal, metadata and audit trails for NHS records used in England (Dec 2023).
• NICE guideline NG197: Shared decision making Evidence based recommendations to support consent and documentation (Jun 2021).

Data protection and patient rights

• ICO: What is special category data Defines health data as special category and sets conditions for lawful processing relevant to optical records.
• ICO: Health data and subject access How to handle SARs for health data including third party redaction and exemptions.
• ICO: Records of processing and lawful basis How to document processing activities and lawful bases to meet the accountability principle.

Accessibility and communication adjustments

• Accessible Information Standard overview Duties to identify, record, flag, share and meet communication needs of disabled people in NHS services.
• Accessible Information Standard implementation guidance Practical steps, roles and templates for implementing AIS in services and referrals (Jun 2025).
• Meeting the Accessible Information Standard in the NHS e-Referral Service How AIS requirements are supported in the e-Referral Service workflows (Jun 2024).

Secure sharing and referrals

• Guidance for sending secure email with NHSmail When and how to use NHSmail and encryption for sending patient information securely, including to non secure addresses.
• Registering Optometrists for NHSmail How community optical practices and registrants obtain NHSmail access in England.
• Eye care digital playbook: Secure communication between primary and secondary care Examples and guidance for secure advice and guidance channels between optometry and ophthalmology.

Electronic records, imaging and attachments

• RCOphth: Electronic Medical Records standards for UK ophthalmology services Standards for ophthalmology EMRs including data quality, audit and interoperability expectations (Feb 2024).
• RCOphth: Clinical datasets Datasets defining essential fields to standardise eye care records and support audit (Oct 2024).
• College of Optometrists: What to record Detailed checklist of minimum record content for examinations, advice and referrals in optometric practice.
• Data Security and Protection Toolkit assessment guides Step by step guidance on meeting National Data Guardian data security standards and demonstrating compliance via the DSPT (Sep 2023).

Subject access, confidentiality and safeguarding

• NHS England: Subject access requests Primary care oriented guidance on receiving, verifying and responding to subject access requests lawfully.
• The Caldicott Principles Eight principles for using and sharing confidential patient information on a need to know and minimum necessary basis (Dec 2020).