Documentation is an extremely important part of the optometric exam. It validates that the procedures have been done and confirms that the correct conclusions have been made. It is the foundation of a good doctor and the best defense in the case of a malpractice suit. It is also helpful in providing high quality vision care to the patient on a continuing basis. Documentation includes not only the exam form, but also telephone and written correspondence, informed consent, pre-exam forms, verification of prescriptions, and any instructions and communications surrounding the patient. Basically everything that is done to the patient or encountered with the patient needs to be written down.
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