Optometric clinical record: A compulsory document

Abstract

In daily clinical practice, the Colombian optometrist has to respect current legislation. Therefore, to fulfill the Optometric Ethic Code and Resolutions 1995 of 1999 and 1715 of 2005, he is compelled to implement the document of clinical record with clear criteria of construction and storage, in such a way that the professional, the health team and the patient understand the importance of a unique record where all the patient health conditions are registered, which must be accessible, reserved and private. The clinical record is also important as a legal document for justice and ethic organizations, as a document to dissolve processes among professionals, health teams and patients, supporting all determinations in the content of the record. We do not have to forget that the doctor is responsible to guarantee document’s inalterability, fulfilling ideal conditions for document handling. The optometric clinical record handling is undoubtedly important in visual and ocular health services as a requirement and legal support for health professionals.