Case History and Record Keeping
Learning Objectives
By the end of this lecture, you should be able to:
● Recall statutory requirements and professional guidelines for record keeping.
● Explain ownership and access rights to clinical records.
● Apply rules of confidentiality and consent.
● Understand retention and disposal of records.
● Take and record a structured case history and symptoms accurately.
Part 1: The Law Around Patient Records
1. Access to Records and Data Sharing
● Patients have the right to see their own health records and, in limited cases, those of
others.
● There must be a balance between:
○ Protecting patient information.
○ Sharing data to improve care and public health outcomes.
● Cybersecurity is a recognized threat in healthcare.
● The NHS App allows patients to access GP notes, test results, prescriptions, etc.
● Exceptions: Under-16s or vulnerable groups - people who have decisions made for
them due to their inability to (data access may be limited).
● Patients can opt out of data sharing.
2. Relevant Legislation: Data Protection Act & GDPR
Key obligations under GDPR:
● Keep accurate and up-to-date patient records.
● Use data only for the intended purpose.
● Amend inaccurate data and respond to objections if use may cause harm or distress.
● Keep data only as long as necessary; dispose of it securely.
● Ensure confidentiality and security.
● Provide patients with a copy of their records free of charge.
● If you acquire patient records (e.g., via practice sale), you inherit these responsibilities.
, 3. Statutory Requirements for Record Keeping
● Maintain full, accurate, contemporaneous records (paper or electronic).
● Safeguard confidentiality in use, storage, and disposal.
● Electronic Patient Records (EPRs):
○ Require secure processes, staff training, regular backups, and safe disposal.
● Ownership: Records belong to the practice, not the patient.
4. Professional Guidance
● College of Optometrists Guidance:
guidance.college-optometrists.org
● Association of Optometrists (AOP):
aop.org.uk/advice-and-support/regulation/uk
● Maintain clear, legible, and logical records (paper or electronic).
● Include all findings, advice, and actions.
● Records should allow another practitioner to continue care seamlessly.
● Poor or falsified records may count as serious professional misconduct.
5. What Constitutes a Patient Record
Includes:
● History and symptoms.
● Clinical findings and advice.
● Dispensing details.
● Written/verbal communication (letters, referrals, responses).
● Record of all visits and actions taken.
6. Why Keep Records?
● Ensures continuity of care and clinical management.
● Enables other practitioners to take over care.
● Provides legal protection in case of complaints.
Learning Objectives
By the end of this lecture, you should be able to:
● Recall statutory requirements and professional guidelines for record keeping.
● Explain ownership and access rights to clinical records.
● Apply rules of confidentiality and consent.
● Understand retention and disposal of records.
● Take and record a structured case history and symptoms accurately.
Part 1: The Law Around Patient Records
1. Access to Records and Data Sharing
● Patients have the right to see their own health records and, in limited cases, those of
others.
● There must be a balance between:
○ Protecting patient information.
○ Sharing data to improve care and public health outcomes.
● Cybersecurity is a recognized threat in healthcare.
● The NHS App allows patients to access GP notes, test results, prescriptions, etc.
● Exceptions: Under-16s or vulnerable groups - people who have decisions made for
them due to their inability to (data access may be limited).
● Patients can opt out of data sharing.
2. Relevant Legislation: Data Protection Act & GDPR
Key obligations under GDPR:
● Keep accurate and up-to-date patient records.
● Use data only for the intended purpose.
● Amend inaccurate data and respond to objections if use may cause harm or distress.
● Keep data only as long as necessary; dispose of it securely.
● Ensure confidentiality and security.
● Provide patients with a copy of their records free of charge.
● If you acquire patient records (e.g., via practice sale), you inherit these responsibilities.
, 3. Statutory Requirements for Record Keeping
● Maintain full, accurate, contemporaneous records (paper or electronic).
● Safeguard confidentiality in use, storage, and disposal.
● Electronic Patient Records (EPRs):
○ Require secure processes, staff training, regular backups, and safe disposal.
● Ownership: Records belong to the practice, not the patient.
4. Professional Guidance
● College of Optometrists Guidance:
guidance.college-optometrists.org
● Association of Optometrists (AOP):
aop.org.uk/advice-and-support/regulation/uk
● Maintain clear, legible, and logical records (paper or electronic).
● Include all findings, advice, and actions.
● Records should allow another practitioner to continue care seamlessly.
● Poor or falsified records may count as serious professional misconduct.
5. What Constitutes a Patient Record
Includes:
● History and symptoms.
● Clinical findings and advice.
● Dispensing details.
● Written/verbal communication (letters, referrals, responses).
● Record of all visits and actions taken.
6. Why Keep Records?
● Ensures continuity of care and clinical management.
● Enables other practitioners to take over care.
● Provides legal protection in case of complaints.
