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GOC Standard 8: Maintaining Adequate Patient Records in Optical Practice

Enhancing patient safety through clear and reliable documentation

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GOC Standard 8: Patient Records
Why Records Matter
Legal & Regulatory Framework
Record Contents & Structure
Completeness & SOAP in Practice
Computerised and Paper Records
Adapting Examinations
Recording Scans & Images
Technology and Attachments
Altering Records
Confidentiality, Security, and Access
Confidentiality & Access Challenges
Record Disposal & Retention
Reflection & Audit
Exam Pass Notes
Reading List
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Scenario Page 1: Completeness and SOAP in Practice ^[1]

Scenario 1: Missing Information

Scenario

A patient returns for review three months after a note that reads "IOP raised; review". The current clinician opens the record and finds only that brief line; there is no documented history of symptoms, no record of risk factors or systemic steroid use, and no written advice or safety-netting. In clinic the patient says they "weren't sure what to watch for" and admits they did not attend a suggested hospital visit because nothing was given in writing.^[3]^[2]^[4]

How does missing history/advice affect safety and continuity, and what should you record now?^[2]^[6]^[7]

Take a full history now: onset, laterality, symptom trajectory, functional impact (vision changes, pain), and systemic risks (eg steroid use); explicitly document red-flag negatives.^[3]^[2]
Recreate and record the consent/advice given today: explain risks, management options, urgency, and provide written safety-netting information to the patient.^[2]^[4]
Add a clear assessment and plan with responsibilities and timelines (who will act, by when); note any re-issued referral and attach or reference any repeat investigations.^[5]^[3]
Completeness is more than numbers; it shows reasoning and ensures the next clinician can act without delay.^[5]^[6]

Scenario 2: Poorly Structured Notes

Scenario

A consultation is recorded as a dense paragraph that mixes the patient's words, device outputs, and proposed actions. At a follow-up visit a colleague cannot tell whether the visual fields were unreliable, whether OCT artefact explains discordant measurements, or what contingency is planned if results change.^[3]^[6]

How does SOAP improve clarity?^[5]

Restructure the consultation into SOAP: place the patient's account and observed signs under S; device outputs, measurements, and reliability comments under O (eg "OCT disc OD/OS attached; signal strength 8/10"); differential reasoning and interpretation under A; and clear actions, timeframes, responsibilities, and contingencies under P.^[5]^[3]
Cross-reference and attach investigations explicitly so readers can access originals.^[3]
Record contingencies in the Plan (eg "if glare persists, trial X; if VA drops ≥1 line, return sooner").^[4]^[2]
SOAP makes intent explicit, prevents omissions, and accelerates safe continuity of care.^[5]^[6]

References (numbered in text)

8. Maintain adequate patient records — Standards of practice for optometrists and dispensing opticians. General Optical Council. Find (opens in a new tab)
Recording your work clearly, accurately, and legibly; Recording decisions — Good medical practice. General Medical Council. Find (opens in a new tab)
Patient records — College of Optometrists (guidance on what to record, imaging, IOP, visual fields, attachments). Find (opens in a new tab)
Daniel Jones; Laurie Dunn; Ian Watt; Una Macleod. Safety netting for primary care: evidence from a literature review. British Journal of General Practice (2019). Find (opens in a new tab)
Weed LL. Medical records that guide and teach. New England Journal of Medicine (1968). Find (opens in a new tab)
Clarke A.; Adamson J.; Watt I.; et al. The impact of electronic records on patient safety: a qualitative study. BMC Medical Informatics and Decision Making (2016). Find (opens in a new tab)
An introduction to good record-keeping. Dental Defence Union (DDU). 3 March 2022. Find (opens in a new tab)

Key Points

Please take a moment to review these points, reflect on their significance and consider how they apply to your own experiences.

Tick to confirm (optional):

Always take and record a full history (onset, laterality, systemic risks, functional impact) and document red-flag negatives.
If prior advice is missing, recreate and document consent/advice given today and provide written safety‑netting.
Use the SOAP structure to separate Subjective (patient words), Objective (tests, device outputs, reliability), Assessment (differential reasoning) and Plan (actions, timeframes, responsibilities).
Cross-reference and describe attachments (e.g. OCT disc OD/OS; signal strength) so images and reports are clearly linked to the note.
Record clear assessment and an actionable plan with timelines and named responsibilities to enable safe continuity of care.
Completeness includes clinical reasoning, not just numeric values, so the next clinician can act without delay.

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Record Contents & Structure Computerised and Paper Records

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Course Snapshot

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Length: 60 minutes CPD (1.00 CE Credits)
Appropriate for: Optometrists, dispensing opticians, practice managers, practice nurses and administrative staff involved in record keeping and information governance in optical services.
Course Price: Free
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Harvard

Mecourse Lifelong Learning (2025) ‘Scenario Page 1: Completeness and SOAP in Practice’. Mecourse Lifelong Learning [Online]. Available at: https://www.mecourse.com/scenario-page-1-completeness-and-soap-in-practice [Accessed 12 May 2026].

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Mecourse Lifelong Learning. Scenario Page 1: Completeness and SOAP in Practice [Internet]. Mecourse Lifelong Learning; 2025 Aug 22 [cited 2026 May 12]. Available from: https://www.mecourse.com/scenario-page-1-completeness-and-soap-in-practice.

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Mecourse Lifelong Learning. “Scenario Page 1: Completeness and SOAP in Practice.” 2025. https://www.mecourse.com/scenario-page-1-completeness-and-soap-in-practice. Accessed May 12, 2026.

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Mecourse Lifelong Learning. (2025, August 22). Scenario Page 1: Completeness and SOAP in Practice. https://www.mecourse.com/scenario-page-1-completeness-and-soap-in-practice

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Mecourse Lifelong Learning, “Scenario Page 1: Completeness and SOAP in Practice.” Mecourse Lifelong Learning. https://www.mecourse.com/scenario-page-1-completeness-and-soap-in-practice (Accessed: May 12, 2026).

AMA

Mecourse Lifelong Learning. Scenario Page 1: Completeness and SOAP in Practice. Mecourse Lifelong Learning. Published August 22, 2025. Accessed May 12, 2026. https://www.mecourse.com/scenario-page-1-completeness-and-soap-in-practice.

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GOC Standard 8: Maintaining Adequate Patient Records in Optical Practice

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Scenario Page 1: Completeness and SOAP in Practice [1]

Scenario 1: Missing Information

Scenario 2: Poorly Structured Notes

References (numbered in text) Why we include references

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Scenario Page 1: Completeness and SOAP in Practice ^[1]

References (numbered in text)