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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
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Scenario Page 2: Adapting Examinations

Scenario 3: Child with Attention Difficulties

The scene

Scenario

A six-year-old sits on the exam chair, increasingly restless as standard acuity and retinoscopy are attempted. They fidget, lose fixation between targets, and provide inconsistent subjective responses. The parent leans forward, clearly worried about classroom performance, asking for a "definitive" answer today while the child becomes more distracted with each test attempt. You and your assistant consider changing approach to gain reliable information without overwhelming the child.

How do you adapt the examination and record validity?

Use developmentally appropriate tools (crowded pictures/Cardiff cards), objective measures (dynamic retinoscopy/spot autorefractor), and short blocks with breaks. ^[2] ^[3] ^[4]
Document reliability and adaptations, and explain what results mean for function at school; set a brief follow-up for confirmation. ^[1]
Provide written advice to parents on near-work habits and safety-net symptoms. ^[1]

Scenario 4: Patient with Severe Vision Impairment Requiring Assessment

The scene

Scenario

A patient with severe vision impairment is unable to read the chart but reports a new "misty" sensation in the left eye (OS). Attempts at standard subjective testing repeatedly fail; the patient becomes frustrated and anxious. You recognise the need to obtain meaningful clinical data while preserving the patient's dignity and avoiding unnecessary, tiring procedures that are unlikely to help.

How do you obtain meaningful data and preserve dignity?

Switch to functional and objective testing (pupils, confrontational fields, slit-lamp, IOP, OCT/B-scan as available). ^[5] ^[6]
Orient verbally, obtain consent, and avoid low-yield tasks that cause fatigue. ^[5]
Record baseline function (navigation/reading), compare to prior records, and escalate if pathology is suspected, noting precisely which tests were not feasible and why. ^[1] ^[6]

References (numbered in text)

8. Maintain adequate patient records — General Optical Council Find (opens in a new tab)
Testing visual acuity of young children: An evidence-based guide for optometrists — College of Optometrists Find (opens in a new tab)
Paediatric Eye Care (Position Paper) — European Council of Optometry and Optics (ECOO) Find (opens in a new tab)
Prospective evaluation of the Spot (Pediavision) vision screener as autorefractor and in the detection of amblyogenic risk factors compared to Plusoptix and a comprehensive pediatric ophthalmology examination — Journal of the American Association for Pediatric Ophthalmology and Strabismus (JAAPOS) Find (opens in a new tab)
Assessing and managing patients with low vision — College of Optometrists Find (opens in a new tab)
Low Vision: the essential guide for ophthalmologists — Royal College of Ophthalmologists 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):

Use developmentally appropriate and objective tools for children (crowded picture tests, Cardiff cards, dynamic retinoscopy, autorefractor).
Break assessments into short blocks with rests; avoid low‑yield tasks that increase fatigue or distress.
Document test reliability, all adaptations made, and limitations of findings; set and record a clear follow‑up plan.
Provide written advice and safety‑netting for carers/parents, and record communication given.
For severe vision impairment use functional and objective testing (pupils, confrontational fields, slit‑lamp, IOP, OCT/B‑scan) and compare to prior records.
Obtain verbal orientation and consent, preserve dignity, and explicitly record which tests were not feasible and why.
Record baseline functional abilities (navigation/reading) and escalate promptly if pathology suspected.

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Computerised and Paper Records Recording Scans & Images

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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 2: Adapting Examinations’. Mecourse Lifelong Learning [Online]. Available at: https://www.mecourse.com/scenario-page-2-adapting-examinations-nnot [Accessed 12 May 2026].

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Mecourse Lifelong Learning. Scenario Page 2: Adapting Examinations [Internet]. Mecourse Lifelong Learning; 2025 Aug 22 [cited 2026 May 12]. Available from: https://www.mecourse.com/scenario-page-2-adapting-examinations-nnot.

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Mecourse Lifelong Learning. “Scenario Page 2: Adapting Examinations.” 2025. https://www.mecourse.com/scenario-page-2-adapting-examinations-nnot. Accessed May 12, 2026.

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Mecourse Lifelong Learning. (2025, August 22). Scenario Page 2: Adapting Examinations. https://www.mecourse.com/scenario-page-2-adapting-examinations-nnot

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Mecourse Lifelong Learning, “Scenario Page 2: Adapting Examinations.” Mecourse Lifelong Learning. https://www.mecourse.com/scenario-page-2-adapting-examinations-nnot (Accessed: May 12, 2026).

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Mecourse Lifelong Learning. Scenario Page 2: Adapting Examinations. Mecourse Lifelong Learning. Published August 22, 2025. Accessed May 12, 2026. https://www.mecourse.com/scenario-page-2-adapting-examinations-nnot.

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GOC Standard 8: Maintaining Adequate Patient Records in Optical Practice

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Scenario Page 2: Adapting Examinations

Scenario 3: Child with Attention Difficulties

The scene

Scenario 4: Patient with Severe Vision Impairment Requiring Assessment

The scene

References (numbered in text) Why we include references

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