Record Contents and Structure

Adequate records are not long by default; they are structured, complete, and proportionate to risk. ^[4][2] The SOAP framework provides a consistent logic that mirrors the clinical process, improves readability, and supports audit. ^[6] Using SOAP does not preclude narrative detail-it ensures detail sits where others expect to find it. ^{[6][4] [1][2]}

Minimum content for optical records

• History: presenting complaint with onset, duration, severity, laterality; ocular/systemic history; medications (e.g., steroids, anticoagulants); allergies; family history; functional impact (driving, work, school). ^[2][4]
• Findings: VA with method, refraction details, slit-lamp observations, IOP with device/time, fields (strategy, reliability), imaging (device/version), and pertinent negatives (e.g., "no RAPD"). ^[2][5]
• Advice and consent: information given, risks/benefits/alternatives, teach-back confirmation, accessibility adjustments (interpreter, large print). ^[3][7]
• Plan and follow-up: review interval, self-care, red-flag safety-netting, referral route/urgency, who will contact whom by when. ^[1][2][5]

Recording all participants and authorship

Records should clearly identify who was involved in the consultation and who authored the entry. This includes:

• The examining or dispensing practitioner, with full name and signature (for paper notes) or secure user ID (for electronic records).

• Any supervising colleague or secondary clinician contributing to care.

• Students, trainees, or assistants present, and their role.

• Interpreters, chaperones, or carers involved in communication or decision-making.

Making these details explicit ensures accountability, supports continuity, and provides a defensible record of who contributed to the patient’s care.^{[1][3] [6][2]}

Applying SOAP in optical practice

• Subjective: the patient's words and context-"letters 'ghost' at night; worse on motorways," health beliefs, and priorities. ^[6]
• Objective: reproducible measurements and observations-include reliability (e.g., fields false positives) and device identifiers. ^[2][5]
• Assessment: differential diagnosis with reasoning-why findings support/argue against each possibility; risk modifiers (myopia, steroids). ^[6][4]
• Plan: agreed actions-treatment, monitoring, referral, and contingencies ("if X occurs, do Y"), with roles and timelines. ^[1][6]

Well-structured records avoid ambiguity.

^[4]

For example: "IOP 26/27 mmHg (GAT, 12:05), thick corneas + R NFL notch on OCT; assessment: glaucoma suspect; plan: same-day non-urgent glaucoma referral per pathway; patient informed, driving advice given." ^[5][1][3] Clarity improves when measurements sit next to their methods and when attachments are referenced in-text ("see OCT macula 2025-08-19"). ^[4][2] Templates that prompt for red-flag screening and consent, while leaving space for subtle clinical reasoning, are often effective. ^[1][3]

References (numbered in text) Why we include references

1. 8. Maintain adequate patient records, General Optical Council Find (opens in a new tab)
2. Patient records, College of Optometrists Find (opens in a new tab)
3. Consent, College of Optometrists Find (opens in a new tab)
4. Good Medical Practice: Recording your work clearly, accurately, and legibly, General Medical Council Find (opens in a new tab)
5. Glaucoma: diagnosis and management (NICE guideline NG81, 2017; updated 2022), National Institute for Health and Care Excellence Find (opens in a new tab)
6. Luiz Miguel Santiago; Isabel Neto. SOAP Methodology in General Practice/Family Medicine Teaching in Practical Context. Acta Médica Portuguesa. 2016 Find (opens in a new tab)
7. Peggy H Yen; A Renee Leasure. Use and Effectiveness of the Teach-Back Method in Patient Education and Health Outcomes. Federal Practitioner. 2019 Find (opens in a new tab)