Professional Ethics, Communication and Record Keeping
What the exam tests
Professional Ethics, Communication and Record Keeping tests consent, confidentiality, scope of practice, communication with visually impaired patients and medico-legally sound documentation.
Ethics and communication
Obtain informed consent before any procedure and explain what will happen in plain language. Keep patient information confidential; do not discuss cases in corridors or on social media. Work within your scope: an ophthalmic technician assists, measures and records but does not independently diagnose or prescribe. When speaking to a visually impaired patient, identify yourself, say when you are leaving, offer your arm rather than pushing, and describe instruments before touching.
Record keeping
Write entries legibly with date, time, findings, advice given, and your name and designation. Record visual acuity for each eye, with and without correction, plus pinhole where relevant. Correct mistakes with a single line and your initials; never overwrite or use correction fluid. Store records securely and release them only through proper authority.
Worked example
A patient asks, “Doctor will definitely restore my sight after cataract surgery, no?” Reasoning: do not promise a guaranteed result. Explain that cataract surgery usually improves vision but that the outcome depends on the retina and other factors, and that the ophthalmologist will discuss risks. Record that counselling was given.
Traps
Do not obtain consent by pressure, disclose results to a relative without permission, sign for a colleague, or alter a record after the fact. Avoid giving a diagnosis or prognosis outside your role, and never ignore a patient's complaint because the clinic is busy.