{
  "url": "https://openlegislation.uk/national-health-service-general-ophthalmic-services-scotland-amendment-regulations-2010/schedule-3",
  "json_url": "https://openlegislation.uk/national-health-service-general-ophthalmic-services-scotland-amendment-regulations-2010/schedule-3.json",
  "legislation": "ssi/2010/86",
  "legislation_title": "The National Health Service (General Ophthalmic Services) (Scotland) Amendment Regulations 2010",
  "legislation_url": "https://openlegislation.uk/national-health-service-general-ophthalmic-services-scotland-amendment-regulations-2010",
  "path": "schedule/3",
  "kind": "schedule",
  "number": "3",
  "heading": null,
  "text": "“SCHEDULE 5\nRECORDS\nRegulation 2(1)\n1. An ophthalmic medical practitioner or optician shall keep the following data in records (this data is a record of patient details, symptoms, tests performed and results thereof):—\nPersonal Patient Data (primary eye examination)\nName, title, address, telephone number, Date of Birth, General Practitioner’s details, Community Health Index number (where available), occupation, driver Yes/No, relevant interests, date of examination\nSymptoms & History (primary eye examination)\nPresenting signs & symptoms and reason for visit, past ocular history, past medical history, family ocular and patient’s own medical history, medication, reason for referral to or from the ophthalmic medical practitioner or optician, smoker yes/no (if relevant), if family history, or symptoms of age related macular degeneration.\nPersonal Patient Data (supplementary eye examination)\nUpdate of Name, title, address, telephone number, General Practitioner’s details, occupation and date of examination\nSymptoms & History (supplementary eye examination)\nPresenting signs & symptoms, reason for visit or for referral to or from the ophthalmic medical practitioner or optician, update of ocular and medical history and medication\nFor all eye examinations:\nDiagnosis / Findings\nRecord of all findings and any diagnosis or outcomes. Record of reason why any specified/expected procedure or test was not carried out. Where digital fundus photographs have been taken, the photographs should be retained either in electronic form or in hard copy and backed up either in electronic form or hard copy.\nWhere a drug has been issued to a patient, a record of the batch number of that drug, the expiry date and the date when that drug was administered to the patient should be kept, either in the patient record or in a register held at the practice for the specific purpose of recording the drugs which have been administered.\nCommunication\nNote any advice, statements, reports or referrals issued to the patient or made on behalf of the patient\nData to be recorded where appropriate for tests and procedures specified in the Tables A and B in Schedule 3 and the Table in Schedule 4:\nExternal Examination\nA record of all relevant findings, technique and apparatus used\nInternal Examination\nA record of whether this was with or without mydriasis, the technique, apparatus and diagnostic agents used and a full description of the ocular media, fundus, blood vessels, optic disc and macula\nNeurological Assessment\nAll relevant tests undertaken, which may include pupil assessment – relative size, shape, direct, consensual and near responses\nOculo-Motor Function\nAll relevant tests undertaken which may include cover test, convergence, muscle balance, motility, stereopsis, amplitude of accommodation\nVisual Fields\nRecord findings, technique and apparatus used\nIntra Ocular Pressure\nIntra ocular pressure measurement, type of tonometer and time of measurement\nSight test\nObjective/subjective findings, unaided vision, pinhole acuity, visual acuity, back vertex distance (over 5D), prescription issued, dispensing details\nColour Vision\nRecord findings and test procedure\nImaging\nRecord reference to any electronic images taken. Where any electronic images have been taken, the image should be retained either in electronic form or in hard copy and backed up either in electronic form or hard copy.\n”",
  "extent": null,
  "status": null,
  "version": "current",
  "annotations": [],
  "outstanding_effects": [],
  "provenance": {
    "source": "legislation.gov.uk",
    "source_url": "https://www.legislation.gov.uk/ssi/2010/86/schedule/3",
    "retrieved_at": "2026-10-28T21:57:02.373955+00:00"
  },
  "licence": "Open Government Licence v3.0",
  "licence_url": "https://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/",
  "attribution": "Contains public sector information licensed under the Open Government Licence v3.0. Source: legislation.gov.uk, The National Archives."
}