Recordkeeping and contact lens practice.

Abstract

Recordkeeping in contact lens practice may be based on a problem-oriented system that emphasizes the use of forms. Fitting agreements and informed consent agreements are the most important components of such a system. Progress notes are also used to document the episodic care that is an integral part of contact lens practice. Examination findings should be described with descriptive language whenever possible; warnings, diagnoses, patient management, and recall and referral appointments should be conscientiously documented in the record of care.