About this course
Good patient records are central to safe optical care. This course helps you apply GOC Standard 8 and UK law to everyday documentation, improving patient safety, information governance and professional protection.
This course is relevant to the whole optical practice team.
CPD Time: 90 minutes (1.50 CE Credits)
Assessment: 10 MCQs. Pass mark 80%. more…
On passing the assessment you will immediately receive a CPD Certificate.
Customer feedback on this course
- Clear, practical guidance that improved our record templates immediately.
- Excellent focus on imaging provenance — highly relevant to our practice.
- Useful SOAP examples that speed documentation while keeping clinical reasoning.
- Good balance of legal framework and hands-on tips for EHR configuration.
- Valuable for staff at all levels; we ran an audit the week after completing the course.
Aim:
The aim of this course is to ensure registrants can create and maintain adequate, accurate, legible and timely patient records that meet GOC Standard 8 and relevant NHS and data protection requirements.
Course objective:
• Explain the legal, regulatory and professional framework for record keeping in UK optical practice (GOC, NHS Records Management Code, GDPR).
• Apply best practice for structuring, storing, amending and securing paper and electronic records, including imaging metadata, SOAP notes and retention/disposal rules.
Anticipated learning outcomes:
The learner will:
• create accurate, complete records compliant with GOC and NHS standards.
• structure consultation notes using the SOAP format for clear continuity of care.
• manage electronic and paper records securely, including imaging and attachments with correct metadata.
• apply correct amendment procedures and preserve audit trails when altering records.
• respond lawfully to subject access requests and follow NHS retention and secure disposal schedules.
GOC Development Outcomes:
Standard 8
Learning content:
Introduction: Why Records Matter | Legal and Regulatory Framework | Record Contents and Structure | Scenario: SOAP in Practice | Computerised and Paper Records | Scenario: Adapting Examinations | Recording Scans, Images and Attachments | Altering Records | Confidentiality, Security and Access | Scenario: Confidentiality and Access Challenges | Record Disposal and Retention | Reflection and Audit | MCQ | Reading List
View full course description
GOC Standard 8: Maintaining Adequate Patient Records in Optical Practice
Course Description
GOC Standard 8: Maintaining Adequate Patient Records in Optical Practice
This course equips optical staff with practical skills to produce records that support safe care, defend clinical decisions and meet regulatory expectations. It translates GOC Standard 8, NHS guidance and data protection law into clear, repeatable record-keeping habits.
Introduction: Why Records Matter
Explains the role of records in patient safety, continuity of care and professional defence. Covers principles of contemporaneous, factual and proportionate entries and common functions such as consent, communication and audit.
Legal and Regulatory Framework
Summarises GOC Standard 8, the NHS Records Management Code of Practice, UK GDPR and the Data Protection Act. Covers professional accountability and Caldicott principles relevant to optical practice.
Record Contents and Structure
Defines minimum record contents and introduces the SOAP framework (Subjective, Objective, Assessment, Plan). Provides example entries, templates and guidance on recording accessibility adjustments and safety-netting.
Scenario: Completeness and SOAP in Practice
Uses scenarios to show the patient safety impact of missing history or advice. Demonstrates recreating consent, restructuring notes into SOAP and clarifying assessment, plan and responsibilities.
Computerised and Paper Records
Covers benefits and risks of EHRs, role-based access, templates and audit trails. Discusses hybrid workflows, scan-and-link procedures and protocols for downtime and back-entry.
Scenario: Adapting Examinations
Addresses adapting tests for children or patients with attention difficulties, documenting reliability, and recording objective baselines for severe visual impairment.
Recording Scans, Images and Attachments
Specifies required metadata and provenance for images: device identifiers, operator, date/time and laterality. Covers storage, backups, read-only finalised outputs and secure sharing.
Altering Records
Explains correct correction procedures: addenda, dated and signed entries while preserving originals and audit trails. Warns against back-dating or overwriting and advises on disclosure to patients.
Confidentiality, Security and Access
Details technical safeguards (authentication, encryption), behavioural controls, minimum-necessary sharing and lawful bases. Covers SAR handling and safeguarding exceptions.
Scenario: Confidentiality and Access Challenges
Shows how to respond to family requests, verify identity, manage full SARs including images and redaction, and record disclosures and requests.
Record Disposal and Retention
Explains NHS retention schedules, tracking legal holds, secure destruction methods and evidencing disposal through certificates and registers.
Reflection and Audit
Encourages using records for reflective practice and CPD. Describes designing practical audits, sampling, setting standards, implementing actions and re-audit to close the improvement loop..
Reading List
Includes GOC Standard 8, NHS Records Management Code, ICO guidance, College of Optometrists and RCOphth resources, Accessible Information Standard and NHSmail guidance.
Course Completion
Participants complete a feedback survey, take a multiple-choice exam and receive a CPD certificate on passing. The course emphasises applying SOAP, correct imaging provenance and lawful SAR handling in practice.
You can copy and adapt this example PDP entry for your own needs and circumstances.
| PDP Learning or Maintenance need |
| Maintain records that meet GOC Standard 8 and NHS requirements |
| How does this relate to my field of practice? |
| Essential for safe patient care, referrals, medico-legal protection and information governance in optical practice. |
| Which development outcome(s) does it link to? |
| Standard 8 / Records & Governance |
| What benefit will this have to my work? |
| Improved continuity, clearer handovers, compliant data handling and reduced legal/regulatory risk. |
| How will I meet this learning or maintenance need? |
| Complete this course and apply SOAP, secure imaging, correction and retention practices in daily records. |
| When will I complete the activity? |