09 Record Keeping

RECORD KEEPING
EST
AUTHOR (s)
Brien Holden Vision Institute Faculty: Jane Kierath, Sonja Cronjé, Neilsen de Souza, Shoshana Jackofsky,
David Wilson, Mitasha Marolia, Gerd Schlenther, Naomi Freuden, Peter Mohlala Brien Holden Vision Institute,
Sydney, Australia
REVIEWER (s)
Bob Chappell Past President: World Council of Optometry (WCO)
THINK
A child you saw two years ago has a scar on the cornea.
You need to know:
 If this is a new or old scar?
 If somebody else has examined the child before?
 What tests were performed?
 What the results were?
WHAT YOU WILL LEARN
When you’ll have worked through this unit you should be able to:
 Recognise the importance of keeping a record
 List the details that should be included in a record
RECORD KEEPING
 A record is a document that provides information about a person’s eye test.

 Records are important as they allow you to keep a permanent copy of what happened each time the person visited
you.
 When the person has their eyes examined again in the future, the examiner will know if the person’s eyes are
getting better or worse.
 Anyone who looks at a person’s record should be able to know what the person’s problems were and what was
done about them.
 It is important that the information that is written on the record is written neatly and can be easily understood.
 Record cards can be filed by name or by number.
June 2012, Version 1-1 Record Keeping, Chapter 9-1

Record Keeping
WHAT DO WE NEED TO RECORD
WHAT INFORMATION IS IN A RECORD?
The date of each visit

The person’s full name
DETAILS OF THE The person’s date of birth or age (if known)
PERSON: Male or female
Contact details (address, phone number)
Where you saw the person (name of hospital, clinic or other).
A summary of the information gathered about the patient

 Chief complaint and history
 Eye health and family history
CASE HISTORY:
 General health and medication
 Visual needs
 Distance and near vision.
Visual Acuity measured at distance and near

VISUAL ACUITY:  With their own spectacles (aided)
 Without spectacles (unaided)
What you saw and did during the examination

EXAMINATION:
Details of the person’s eye health
What you identified to be the problem and how you intend to manage it
PLAN:  Prescription of spectacles and medication
 Referral
What you told the person

 Explanation of their symptoms / your findings
 Medication / treatment plan and why you have decided on this mode of action
ADVICE:
 When to use the medication or follow the course of treatment
 In cases of referral and explanation as to why they need to be referred and when
they need to return for a follow-up visit.
 You must complete the record by printing and signing your name.
SIGNATURE
 It is not a legal document unless it is signed by the examining practitioner
RECORD THE RESULT EVEN IF IT IS NORMAL

 This means that you should write down positive findings as well as negative
findings e.g. distance vision is good or cornea is clear.
 This shows that you have done the test.
If a box has been left empty on the record form, it means the test was not done.

Record Keeping
TEST YOURSELF QUESTIONS
1. Why is it important to keep good eye examination records?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
2. Why is it important that the information on the record card be written neatly?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
3. What information do we need to write in our record card about a person?

_______________________________________________________________________________________
_______________________________________________________________________________________
4. Why is it important to write down facts even if they are normal?
_______________________________________________________________________________________
_______________________________________________________________________________________

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RECORD KEEPING

WHAT YOU WILL LEARN

 A record is a document that provides information about a person’s eye test.

June 2012, Version 1-1 Record Keeping, Chapter 9-1

WHAT DO WE NEED TO RECORD

WHAT INFORMATION IS IN A RECORD?

The date of each visit

A summary of the information gathered about the patient

Visual Acuity measured at distance and near

What you saw and did during the examination

What you told the person

RECORD THE RESULT EVEN IF IT IS NORMAL

June 2012, Version 1-1 Record Keeping, Chapter 9-2

TEST YOURSELF QUESTIONS

1. Why is it important to keep good eye examination records?

3. What information do we need to write in our record card about a person?

4. Why is it important to write down facts even if they are normal?

June 2012, Version 1-1 Record Keeping, Chapter 9-3

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