The forms your clinic uses can be as few or as many as you feel necessary. Most forms exist to help insure complete and proper documentation of the care rendered to your patients.
Proper documentation is essential for continuity of care and the reduction of risk to the patient.
Documentation also provides a permanent record of the patient's ocular health and refractive status as well as your diagnosis, treatment and recommendations. Entries into the medical record must comply with a number of specific administrative requirements. You must make your entries actually using these letters as the headings for your entries. The subjective complaints and patient history should be a full and accurate account which clearly reflects the patient's report of their problem, symptoms, and pertinent history. Other requirements for documentation include the date, clinic stamp, signature, and signature stamp.