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Ophthalmology Documentation Audit
Date
DD slash MM slash YYYY
Auditor
Name
Record Keeping
Is documentation (where necessary) legible?
*
Yes
No
N/A
Are they fully complete (including the n/a boxes)
*
Yes
No
N/A
Are they signed?
*
Yes
No
N/A
Are they dated?
*
Yes
No
N/A
Pre-assessment Documentation
Was the patient appropriate for surgery?
*
Yes
No
N/A
Was the biometry measurement carried out and reviewed?
*
Yes
No
If 'No', why?
Was the patient fit for local anaesthetics- topical drops?
*
Yes
No
N/A
Has the patient been referred to the GP?
*
Yes
No
N/A
Please state reason for referring the patient to the GP?
*
For patient on Warfarin tablet. Was the patient been advised to attend the Warfarin clinic for INR test a week before the surgery date?
*
Yes
No
N/A
Was an interpreter booked?
*
Yes
No
N/A
Is the anaesthesia clearly stated?
*
Yes
No
N/A
If not please state the reason
Is it documented that the patient is able to lie flat for at least 1 hour for surgery?
*
Yes
No
N/A
