Patient record cards

Patient record cards

C10.1.1 It is essential in the interests of both registered dispensing optician and patient that full and accurate records, either hard copy or electronic, are kept and stored in a systematic and efficient manner.

C10.1.2 ABDO takes the view that it is the duty of all registered dispensing opticians to ensure that information of a personal nature entrusted to their care be treated as confidential and divulged only with the patient’s consent or when disclosure is required by law. Recorded information should include:

  1. Full name, address and daytime telephone number.
  2. Date of birth.
  3. Occupation (necessary knowledge for giving advice and guidance in dispensing spectacles).
  4. Recreation (for the same reasons as Occupation).
  5. General Practitioner’s name and address.
  6. The prescription.
  7. Measurements, tints, coatings etc, facial measurements and centration distances.
  8. Details of any other services provided – i.e. low vision aids.
  9. Charges and fees.

C10.1.3 Note: If the General Optical Council (GOC) requests information from the dispensing optician, the dispensing optician should, subject to any statutory restrictions, promptly give the GOC the information that is requested. If such information is not supplied within fourteen days the GOC may seek a court order requiring that the information be produced (unless this is prohibited by any other enactment e.g. the Data Protection Act.)

C10.2.1 It is essential in the interests of both the registered dispensing optician and the patient that full and accurate records, either hard copy or electronic, are kept and stored in a systematic and efficient manner. The retention period for records must be greater than the statutory limitation period. These periods will cover:

  1. The statutory limitation period which allows claims to be brought within: a) 6 years for contractual matters; b) 3 years for personal injury. The three year period runs from the time that someone becomes aware that they have grounds for a claim (therefore reliance cannot be made on claims being brought within 3 years of the patient being seen).
  2. The NHS requires NHS patients’ records to be retained for seven years.

C10.2.2 Minors, that is children under 18 years old, are entitled to bring claims in respect of personal injury upon reaching their majority, i.e. on becoming 18 years old, and for three years thereafter. Therefore their records should be kept until they are 21 years old, and it is recommended that they are kept until they are 25 years old.

Note: In view of the fact that hospital records should be kept for 10 years, it is suggested that it is wise to use a blanket 10 year rule for the retention of all adult patient records. This does not conflict with the fifth data protection principle because the purpose of retaining patient data includes complying with the dispensing optician’s ongoing legal and professional obligations. Before destroying any patient record, dispensing opticians should satisfy themselves that they will have no further need for that record. Disposal should be done securely.

C10.2.3 The dispensing records remain the property of the practice, however the Data Protection Act 1998 confers upon living patients and, in certain circumstances, other interested persons, the right of access to records held by, amongst other medical and paramedical practitioners, registered dispensing opticians. For deceased patients similar provisions are made in the Access to Health Records 1990. Patients also have a right to an explanation of the records and a right to copies. A charge of up to £50 can be made for supplying copies (if the dispensing optician thinks it appropriate). Where records are considered to be inaccurate, the patient has a right to have those records corrected. Accordingly it is necessary that a registered dispensing optician’s records are complete, intelligible, reliable and maintained in a way which would not produce difficulties or embarrassment if examined by persons unconnected with the holder’s profession or practice. The Act allows 40 days for response to an application for access to records. However, under the Access to Health Records Act, the practitioner may withhold the record if, in his or her judgement, it would be harmful to the patient to release it, although such a decision must be justified in the event of a dispute.

C10.2.4 Information on access to records -BMA https://www.bma.org.uk/advice/employment/fees/medical-records

C10.2.5 If a registered dispensing optician is uncertain about the appropriate response, it is important that, without undue delay, legal advice or advice from ABDO is sought.

C10.3.1 Many practices are now equipped with electronic record systems. In such cases it is necessary to register as data users under the terms of the Data Protection Act 1998. Details and application forms are available from the Data Protection Register, Information Commissioners Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF, Tel. 01625 545745. It is important that compliance with the Data Protection Act’s requirements concerning patient information, including publication of information to third parties, for example other opticians, and medical practitioners, is observed. In particular, patient permission should be obtained to record data and screen privacy should be maintained to ensure such data remains confidential.

C10.4.1 The owner of the practice where a sight test takes place owns all records, including the clinical records. However to avoid any dispute over ownership it is advisable to include a clause clarifying ownership in any contract of employment, including any agreement with a temporary employee or a locum.

C10.4.2 The confidentiality of records means that they should, in no circumstances, be passed on in a change of ownership of the practice to other than a registered optician, registered medical practitioner or enrolled body corporate and the patient must be notified. Should patients themselves choose another registered practice it is appropriate to provide a copy of the dispensing records on request as being in the best interests of all concerned, it is advisable to obtain signed authorisation from the patient before passing on the copy of the dispensing record.

C10.4.3 Registered dispensing opticians who end employment in a practice in order to set up their own practice or work for a new employer must not use the records or their knowledge of the records of their previous practice for the purpose of canvassing for potential patients for their new practice.

C10.5.1 When a practice is sold or otherwise disposed of, or when a particular practice association ends, registered dispensing opticians have a duty to ensure the continuing welfare of patients. In the case of closure, arrangements should be made for the transfer of patients’ records to another practice. When the practice is transferred, the public, and in particular existing patients, should be informed and the new owners identified. If it is not possible for the records to be transferred to another practice, rather than their being destroyed, records should be offered to the Primary Care Organisation (PCO) or a person nominated by the PCO.