Recording Scans, Images, and Attachments

Imaging and perimetry are integral to modern optical practice.^[5] Their medico-legal value depends on identity, integrity, and interpretability years later.^[1][3] An image without provenance is nearly as risky as no image at all.^[7][6]

Metadata and linkage that must be present

• Patient identifiers: full name, date of birth, unique ID; laterality embedded on the image where possible.^[1][2]
• Acquisition details: device/model/software version, operator, date/time, fixation strategy or scan protocol, and image quality metrics (e.g., signal strength).^[6][5][2]
• Clinical context: brief indication ("raised IOP; RNFL analysis"), and where it fits in the encounter ("pre-dilation fields").^[2][1]

Images and plots should be stored in the patient's record, not solely on device workstations.

^[3][2]

Consistent naming conventions reduce error; local desktop folders are best avoided.^[3][2] When exporting for referral, secure channels are preferable and a short text summary that explains relevance can aid interpretation.^[4][2][7]

Handling, storage, and sharing protocols

• Integrity: apply read-only status to finalised outputs; all edits should generate a new version with audit trail.^[6][3][2]
• Resilience: back up to encrypted, access-controlled storage; test restorations on a schedule.^[3]
• Sharing: when sharing with hospitals, follow local pathways (NHSmail, approved portals) and log what was sent, to whom, and when.^[4][3]

If misidentification occurs, it is safer to correct immediately with an addendum that references the erroneous record and the fix applied. Originals should not be deleted or overwritten.^[3][2] Training for all staff who touch devices - covering identity checks at acquisition and end-of-day reconciliation of "unlinked" studies - reduces recurrence.^[2][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. Imaging / Patient records — The College of Optometrists Find (opens in a new tab)
3. Records Management Code of Practice for Health and Social Care — NHS Transformation Directorate (NHSX / NHS England) Find (opens in a new tab)
4. Guidance for sending secure email (including to patients) — NHSmail / NHS England Digital Find (opens in a new tab)
5. Ophthalmic Imaging — The Royal College of Ophthalmologists Find (opens in a new tab)
6. A.5 Audit Trail Message Format Profile — DICOM Standard (NEMA) Find (opens in a new tab)
7. John F Nettrour; M Benjamin Burch; B Sonny Bal. Patients, pictures, and privacy: managing clinical photographs in the smartphone era. Arthroplasty Today. 2018. Find (opens in a new tab)