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The National Health Service (General Ophthalmic Services) (Scotland) Regulations 2006

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1.  An ophthalmic medical practitioner or optician shall keep the following data in records (this data is a record of patient details, symptoms, tests performed and results thereof):–

Personal Patient DataName, title, address, telephone number, Date of Birth, General Practitioner’s details, occupation, driver Yes/No, hobbies
Symptoms & HistoryPresenting signs & symptoms, past ocular history, past medical history, family ocular and patient’s own medical history, medication, reason for referral to or from the ophthalmic medical practitioner or optician, Smoker Yes/No
External ExaminationA record of all relevant findings
Internal ExaminationA record of whether this was with or without mydriasis, the apparatus and diagnostic agents used, and a description of the ocular media, fundus, blood vessels, optic disc and macula
Pupil AssessmentRelative afferent pupillary defect, direct, consensual and near responses, pupil size and shape
Extra Ocular Motor FunctionCover test, convergence, muscle balance, motility, stereopsis, amplitude of accommodation results
Visual FieldsRecord relative findings, apparatus, confrontation
Intra Ocular PressureIntra ocular pressure measurement, contact or non-contact
RefractionObjective/subjective findings, unaided vision, pinhole acuity, visual acuity, back vertex distance, prescription issued, spectacle, dispensing details
Colour VisionRecord findings and test procedure
ImagingRecord reference to any electronic images taken
Supplementary Additional ProceduresNote the reason for any supplementary or additional procedures
Diagnosis / FindingsMake a record of all findings and any diagnosis
CommunicationNote any advice, statements, reports or referrals issued to the patient or made on behalf of the patient.

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