This article is based on advice shared by Henrik Holton, Expert in The Danish Patient Complaints Agency and optometrist at Synscentralen in Vordingborg, Denmark. The general recommendations below reflect Danish guidelines. Always check and follow your local laws, professional standards, and payer requirements.
Why your record is your best insurance
Record-keeping is a legal obligation. It’s also the single most important piece of evidence if a case is reviewed by a complaints or disciplinary body. A clear, complete, and timely record helps external reviewers understand what you saw, what you thought, and why you acted.
Conversely, inadequate or fragmented notes are themselves considered professionally unsatisfactory and can lead to criticism even when the clinical care was reasonable.
Henrik Holton notes a gradual rise in complaints involving optometrists as the profession’s scope expands (fundus cameras, OCT, perimetry, etc.). With that growth comes responsibility to document objective findings and escalate appropriately (e.g., referral to ophthalmology when indicated).
Good notes make the difference between a fair assessment and avoidable criticism.
Legal-quality standards
Comprehensive, precise and updated
Enough detail for another clinician to reproduce your reasoning and plan. Enter notes as soon as possible. Same day at the latest.
Traceable
Your identity is clear; corrections are additive (no overwriting).
Patient-centered
Document what you told the patient and what you agreed together.
Professionally safe
Missing documentation is treated as missing care.
What a solid optometry record should contain
Below is a pragmatic structure you can adopt in everyday practice. Use headings or EMR fields consistently.
1. Patient identifiers
Full name, national ID/DoB, contact info, and any relevant GP/ophthalmologist details.
2. Date/time and author
Date of encounter, time of key events (especially referrals/phone calls), and the name/signature or electronic identity of the responsible optometrist.
3. Reason for visit (chief complaint / referral reason)
Why the patient came today. Use the patient’s words when helpful: “Letters blur at near in the evening; left eye worse”.
4. History (anamnesis)
Symptoms: onset, duration, laterality, severity, variability, triggers/alleviators.
Red-flag review: flashes/floaters/curtain, sudden vision loss, pain, photophobia, headache, diplopia, systemic symptoms.
Past ocular history: surgery, trauma, disease (e.g., AMD, glaucoma).
Systemic history & meds: diabetes, hypertension, anticoagulants, steroids, new drugs relevant to vision; allergies.
Family history: glaucoma, AMD, retinal disorders.
Social/functional: driving, occupation, visual demands.
5. Visual function
VA with habitual correction (distance and near) OU/OD/OS.
Unaided VA when relevant.
Refraction (method and endpoints) and best-corrected VA.
6. Clinical examination
Document what you examined and what you found. Not just “normal.”
Binocular vision (cover test, motility, NPC, stereopsis as indicated)
IOP (method, time)
Anterior segment (slit lamp description)
Posterior segment / imaging
Dilation status
Fundus description by structure (disc/C:D, macula, vessels, periphery)
Imaging results: fundus photos, OCT (macula/RNFL), perimetry summaries including your interpretation (not just the raw printout)
7. Assessment (impression/diagnosis list)
Tie symptoms + findings together. State your conclusion and clinical reasoning in plain language.
8. Plan and patient communication
Management: prescriptions, trials, device settings, treatment, self-care.
Safety-netting: what to watch for, when to return, what constitutes urgent review.
Referrals: who, why, urgency, and proof of action (referral sent/handed, patient informed).
Follow-up: interval and purpose.
Patient understanding: note that the patient was informed and agreed (or declined) include key phrases you used.
9. Attachments and data
Store and label images/printouts (date/time/eye), and link them to the encounter.
10. Audit trail
Corrections must preserve the original entry (date- and user-stamped).
Red-flag triggers that must show in your notes
- Acute vision loss
- New visual field defect
- Flashes/floaters/curtain
- Eye pain
- Sudden diplopia (double vision)
- Neurologic symptoms
- IOP crisis
- Macular haemorrhage
- Disc oedema
- RAO/CRVO suspicion
- Wet AMD signs
- Retinal tear/detachment suspicion
Example
Background: 70-year-old woman reports reduced vision OS over months.
Good entry (key extracts):
Reason for visit: “Wants better reading glasses; left eye seems worse.”
History: Difficulty with small print; poor task lighting. No systemic meds; no ocular FHx (family history).
VA (habitual visual acuity): OD 1.0, OS 0.5; Near: 0.5M with customary readers.
Refraction → BCVA: OD 1.0; OS 0.5.
OCT: OD normal (C/D 0.3). OS: central drusen + pigmentary changes.
Assessment: Findings compatible with AMD OS; reduced OS acuity consistent.
Plan: Referral to ophthalmology today; written referral provided; defer new spectacles until post-opinion; safety-netting explained; follow-up arranged.
Why this passes scrutiny:
The record shows coherent history, objective findings, interpretation, decision, and executed action.
Criticism for inadequate documentation would be likely if only refraction/VA were recorded without anamnesis, fundus/OCT description, conclusion, and plan.
Final thoughts
Common pitfalls to avoid
- Copy-paste without verification (propagates errors).
- Only numbers, no narrative (e.g., OCT raw values with no interpretation).
- Shorthand that a layperson or external reviewer can’t follow.
- Undocumented referrals (if it isn’t recorded, it didn’t happen).
- Late entries without time-stamped addenda notation.
- Missing patient communication (risks “failure-to-warn” criticism).
A well-structured, timely, and interpretable record protects your patient and your practice.
As Henrik Holton emphasizes, most cases avoid criticism when the clinical work and documentation are sound.
The fastest way to invite criticism is poor or incomplete notes. Build good habits, use a consistent template, and document your reasoning and communication every time.