Documentation

1. Documentation

Systematic and targeted documentation is an important part of any examination or fitting of contact lenses. Detailed documentation helps to make informed decisions, understand and follow the necessary steps in a given case. It is also a sign of high quality health services provided by specialists.

"What has not been documented has not happened", the documentation serves for legal certainty and proof of adequate actions. That is why it is important to follow a structured and clear vision of our card file, so that an external person/expert can get quickly and easily overview and to recognize the accuracy, correctness and completeness of the documentation.
Our documentation can cover individual steps of the examination or a whole cycle of consecutive examinations, such as: anamnesis, refraction, inspection of the anterior and posterior segment of the eye and allow to supplement in-depth observations.

Principles of documentation documentation

a) Legal certainty ´´ What is not been documented has not happened´´!
b) Documentation obligation (e.g. LOT numbers and expiry date of contact lenses)
c) Objectivism
d) Traceability
e) Data protection
f) Ensuring success of the intervention or(Secure placement of Intervention successes)
g) Subsequent optimization possibilities of interventions or (Possibility to optimize the initial intervention)
h) Security for investigators and test subjects / customers
i) Adherence to generally accepted standards
j) Clarity for a quick overview or Structure and legibility for a good overview
k) "No findings" documentation: no change is also a condition!
l) Checklist / CRF for identical documentation ** or / For uniform documentation structure

2. Contents of the documentation (for more information see Checklist)

Depending on the specific examination / examination, different facts must be taken into account, which are important both for the examiner / specialist and for the test person / patient. First of all, an accurate medical history should be taken to give detailed information about the patient. Additional and individual studies, as well as methods and techniques used, assessment schemes, must also be documented. The overall review should not be limited to the points listed here, but should be decided on a case-by-case basis. Examples of what the documentation should contain can be found here:

Below we have summarized some points of possible documentation that do not cover the detailed list:
• Medical history
• Actual refraction
• Inspection of the anterior segment of the eye
• Assessment of the posterior segment of the eye
• Analysis of the tear film
• Monitoring the stabilization of CL
• Explanation of the patient / client