Record keeping and conclusion

Key points

  • Your records are the only evidence of the decisions you made and the actions you took regarding any referral.
  • All relevant clinical details need to be included in referral documentation, including management and advice given, and the reason for referral. If appropriate, include an indication of the urgency for any patient to be next seen.
  • Keep things specific and to the point and remember a GP may not have specialist knowledge of optometry.
  • If not referring through a GP, informing a patient’s GP of what has taken place is recommended.
  • You are obliged to let the patient know why they are being referred and issue a statement of the details of the referral.
  • A patient has the right to choose their secondary care so ensure they are happy with your choice of pathway and, where not, consider the alternatives or discuss with a GP.
  • If you decide not to refer but monitor a condition instead, inform the GP of your activity.
  • For specific pathway referral, always use the required documentation and mode of delivery (for example fax or secure email).