Concerns, Complaints, and Legal/Professional Responsibilities

Dealing with Complaints

• When facing complaints:
  • Think: Consider ways to turn the situation into a positive outcome.
  • Communicate: Maintain regular communication.
  • Own: Take ownership of the problem.
  • Analyse: Try to determine what went wrong.
  • Get Advice: Seek immediate legal advice from your insurer and avoid admitting liability.

Duty of Candour

• The Duty of Candour involves:
  1. Being candid when things have gone wrong.
  2. Offering an apology.
  3. Offering appropriate remedy.
  4. Explaining potential effects.
  5. Stating what actions will be taken to prevent recurrence.
  6. Important Note: Not admitting liability or wrongdoing.
  7. An apology or other step taken does not amount to admission of negligence or breach of statutory duty.

Complaint Destinations

• Complaints can be directed to:
  • The practitioner or their employer.
  • NHS (National Health Service).
  • Trading Standards.
  • Citizens Advice Bureau.
  • Optical Complaints Conciliation Service (OCCS).
  • A solicitor.
  • General Optical Council (GOC).
  • Additional Regulatory bodies (AR).

Complaints to Your Employer

• As an employee, you possess both rights and responsibilities as part of your employment contract.
• Employers address complaints to resolve the issue from the patient's perspective and to assess if contractual responsibilities have been breached.

Complaints to NHS

• Processes differ between England and Wales.
• Practices must have a complaints procedure that includes local resolution.
• If local resolution isn't successful, the patient may approach the NHS directly:
  • In England: Contact NHS England via their complaint process.
  • In Wales: Contact the Health Board with which the practice has a General Ophthalmic Services (GOS) contract.

NHS Possible Sanctions

• Sanctions include:
  • Suspension or removal from the performers list (England) or the ophthalmic or supplementary ophthalmic list (Wales).
  • Suspension or removal of the practice's contract (England) or suspension/removal from the ophthalmic list (Wales).
  • Appeals process is available.

Complaints to Trading Standards

• Administered by the local authority (council).
• Deals with complaints about products:
  • Quality
  • Fit for purpose
  • As described

Complaints to Citizens Advice Bureau

• A charity offering advice on citizen's rights, including consumer rights advocacy.

Complaints to the OCCS

• The OCCS (Optical Complaints Conciliation Service) handles complaints related to optical goods and services, excluding fitness to practice complaints.
• It provides mediation between the patient and practitioner.
• Decisions made by the OCCS are non-binding.

Nature of Complaints to OCCS

• Goods and services: 40%
• Customer care: 29%
• Other: 6%
• Product: 6%
• Charges: 3%
• Patient advice: 6%
• Unknown: 9%
• (Data from OCCS Annual Report 2022-23)

Complaints to a Solicitor

• Usually from individuals seeking compensation.
• The solicitor will attempt to prove negligence, indicating a breach of common law duty.
• Solicitors may pursue claims against the practitioner, their colleagues, and their employer simultaneously.

Common Law Duty

• Practicing to the same standard as a reasonably competent optometrist.
• Providing reasonable care and skill.
• Taking reasonable care in actions or omissions to prevent harm.

Negligence

• Part of civil law of tort.
• A tort is an act or omission that unfairly causes suffering, loss or harm resulting in legal liability.
• Other torts include nuisance, trespass, and defamation.

Proving Negligence

• The plaintiff (patient) must prove, on the balance of probabilities:

  • A duty of care existed.
  • The duty of care was breached.
  • Harm resulted from the breach.

• Limitation Period:

  • Claims must be brought within three years from the date the patient knew or should have known that injuries/clinical conditions were significant and resulted from the act/omission.
  • For a child, the limitation period starts when they turn 18, regardless of when they "knew".

Negligence Claims

• Patient's solicitors may use expert witnesses.
• Insurers may want to settle out of court due to high costs.
• Settlements often include a 'confidentiality clause' to protect reputation.

Damages Awarded

• Courts may award damages based on:
  • Pain and suffering.
  • The effect on enjoyment of life.
  • Loss of earnings and prospects.
  • Expenses, including future medical care.

Responding to a Solicitor's Letter

• If you get a solicitor’s letter:
  • Contact your insurer immediately.
  • Keep full records of what you have done for the patient.
  • Maintain a record of all communications between yourself, the patient (or representative), and your employer.
  • Draft a fresh account of your dealings with the patient and your comments on their complaint, for your information.
  • Acknowledge the letter within 14 days of receipt.

Actions to Avoid

• What you should NOT do if you receive a solicitor’s letter:
  • Do not admit liability to anyone, including your employer.
  • Do not allow your employer to admit liability or act on your behalf.
  • Do not enter into any further discussions or correspondence with any party.
  • Do not offer to settle any claim.
  • Do not incur any costs in connection with a claim or complaint.
  • Do not disclose the terms or nature of your insurance.
  • Do not make any statement or comment that could give rise to a claim of negligence.
  • Do not make any alterations to the patient’s records. Speak to your insurer first.

GOC Complaints

• Anyone can complain to the GOC.
• The GOC can investigate even without a complaint if they become "aware" of a concern.
• Complaints must relate to registrants’ fitness to:
  • Practise (optometrists and dispensing opticians).
  • Carry on business (businesses).
  • Train (students).
• This relates to meeting standards of health, character, knowledge, skill, and behaviour to practice safely and effectively.

GOC Complaint Procedure

• Investigation.
• Interim order (sometimes).
• Fitness to practice committee hearing - Procedural (sometimes) / Substantive Findings.
• Sanction (sometimes).

GOC Complaints - Appeals

• Appeal against findings or sanctions.
• Professional Standards Authority (PSA) may ask the High Court to review a decision it considers too lenient.
• The registrant may appeal to the High Court within 28 days of the decision.

Insurance Coverage

• Medical malpractice insurance covers claims of negligence only.
• It doesn't automatically cover legal defense for complaints to the NHS, OCCS, or GOC.
• Understand the complete package when choosing your insurer.
• AOP & FODO provide “Professional Discipline Cover” for members with other complaints, in addition to medical malpractice insurance.

Optometrist Responsibilities After Eye Exam

• The optometrist must provide the patient with a written statement indicating:
  • That they have carried out the required examinations.
  • Whether they are referring or not (and if so why).
  • Either a signed, written prescription for an optical appliance or a signed, written statement that the patient does not need to wear or use an optical appliance.

Exceptions to Immediate Statement

• Exceptions when a written statement isn't immediately required:
  • The patient is referred to a doctor for further investigation or treatment.
  • The sight test was part of a general medical examination.
  • The patient was resident in a hospital or clinic for treatment when their sight was tested.

Details to Include in Statement

• The date of the sight test.
• The name and address of the patient (and DOB if under 16).
• Optometrist’s name and practice address.
• Spherical power, cylindrical power, and axis.
• Prism power and orientation.
• Near addition.
• A statement that no change in existing appliance is needed or that the patient does not need specs.

GOS Referrals (England vs. Wales)

• Patients with signs of injury/disease/abnormality in the eye/elsewhere which may require medical treatment or are not likely to attain satisfactory vision even with correction should be referred (with consent):
  • In the first instance, to an optometrist with appropriate qualifications.
  • If that wouldn't meet the patient’s needs, refer to an ophthalmic hospital (HES).
• Referrals must be made electronically where available.
• Inform patient’s GP of the referral, providing details.
• Give the patient a written confirmation of the referral with details.
• Patient to acknowledge receipt of prescription on a sight test form.

When to Refer (General Rule)

• Referral should occur when it appears that a person consulting the optometrist/dispensing optician is suffering from an injury or disease of the eye.

Exceptions to Referral

• Patient unwilling to be referred (does not consent).
• In your professional judgement, there is no justification to refer, or it would be impracticable or inexpedient to do so.
• In this case, refer instead to:
  • A person other than a medical practitioner with the appropriate qualifications or expertise to provide medical or clinical treatment.
  • A person or body who organises referrals to a registered medical practitioner or other person with appropriate qualifications and expertise as above.

How to Refer - Documentation

• Record that you have made the referral and its date.
  • Describe the injury or disease.
  • Include any advice or medical or clinical treatment given.
• Provide a written report of your findings with the referral, including:
  • Your grounds for thinking that the person may be suffering from injury or disease of the eye.
  • The urgency of the case.
  • Instructions for the referral booking centre as to who the person should be referred to.

Additional Services

• Provide emergency services in the best interests of the patient.
• Give treatment in line with the Opticians Act:
  • Emergency treatment.
  • Signed orders.
  • Orthoptic treatment.

Referral Considerations

• Considerations:
  • Whether or not to refer.
  • What to do if the patient refuses to be referred.
  • Repeat measures and locums – internal referrals.

Communication After Testing

• After tests, you should tell the patient:
  • What you have found.
  • What you would recommend.

Advice on Next Routine Eye Exam

• There are no guidelines for private sight tests.
• GOS sight tests must be ‘clinically necessary’.
• Use your judgement in advising when to re-attend.

Contact Lenses: Who Can Fit Them?

• Optometrists (almost all).
• Dispensing Opticians (CLOs - Contact Lens Opticians).
• Doctors (all).
• Certain Supervised Persons.

CL Qualifications

• Optometrists and Dispensing Opticians cannot fit CLs unless:
  1. They have an approved qualification:
     • An Optometry qualification entitling first registration after 1961.
     • ABDOs Contact lens diploma.
  2. They have certification (grandfather right).
  3. They are working under the supervision of someone with one of the above.

Contact Lens Fit Requirements

• In addition to the correct qualification, a CL cannot be fitted unless:
  • The patient has a spectacle prescription within 2 years.
  • The fitting begins before any re-examination date specified in the prescription.

What is a Contact Lens Fitting

• Assessment of whether a lens meets the patient’s needs.
• The patient must be provided with:
  1. Signed written specification on completion of fitting:
     • Required for powered lenses only, not plano.
     • Must state period of validity and expiry date.
     • Must include particulars listed in Contact Lens (Specification) Rules 1989.
  2. Instructions and information on care, wear time, cleaning and maintenance of lens:
     • Can be verbal but safer (for practitioner and patient) for it to be in writing.

Sale of Contact Lenses

• Must be by, or under supervision of, an Optometrist, CLO or Doctor when:
  • Patient is under 16.
  • Registered sight impaired / severely sight impaired.
• Non registrant sellers must have:
  • Original specification.
  • Copy of specification verified with the provider of the specification.
  1. The seller must be reasonably satisfied that the goods are intended for use by the person named in the specification.
  2. The specification must be in date when the sale is made.
  3. The seller must be under the “general direction” of : an optometrist, dispensing optician, or a doctor.

Contact Lens Aftercare - Law

• Basic advice to patient on:
  • Contact lens care.
  • The need for routine professional contact lens care.
  • Contact details for emergency care.

College of Optometrists Guidance on CLs

• College of Optometrists Guidance:
  • Infection control – hand hygiene, cross contamination, solution bottles, fitting sets and decontamination.
  • Essential and other CL equipment and facilities – keratometer and slit lamp.
  • Fitting contact lenses – referral to a colleague, self-fitting, supervision of fitting.
  • Contact lens specifications – plano lenses, purchasing lenses elsewhere.
  • Supplying CLs – interpretation of supervision, duty to provide aftercare.
  • Care of and refitting CL wearers – checkup should be at least every 12 months.
  • Specialist CLs – EW, therapeutic & cosmetic, myopia progression.

Non-CL Related Problems

• Make it clear a CL appointment is not a full eye examination.
• Note symptoms and advice given on record.
• Advise patient you will either investigate yourself or refer.
• Signs: Same as if you found them at a sight test – advise and treat / refer as appropriate.
• Symptoms: Similar to emergency appointments.
• If you do not investigate you must refer, not just direct.

CLs and Sight Tests

• A sight test and contact lens appointment can be combined.
  • You will be subject to rules and regulations of both.
• Always remember to discuss CLS at the end of a sight test : Are they an appropriate optical appliance? (Good practice and helpful for patient)

Optical Appliance Defined

• Defined by Opticians Act 1989 as an appliance designed to correct, remedy, or relieve a defect of sight.
• Anyone can sell Optical appliances but there are rules and exceptions in the Opticians Act 1989 and GOC rules.
  1. The appliance is in accordance with a written prescription (e.g., checked on a focimeter by the seller) and has been given by a doctor or optometrist following a sight test within the last 2 years.
  2. The wearer is not:
     • under 16 years old and/or
     • registered sight impaired or severely sight impaired.
  3. The seller has accounted for back vertex distance.
  4. The seller has aligned the optical centres with the wearer’s pupil centres, except where the prescription provides otherwise, i.e., prism.
  5. The appliance complies with British Standards.

Ready Readers

• Can be sold by anyone providing:
  1. The purchaser is at least 16 years old.
  2. The specs have 2 SV lenses of the same spherical power not exceeding $4D$.
  3. The sale is wholly for remedying presbyopia.

Antiques and Second Hand Glasses

• Can be sold by anyone providing:
  • The appliance is sold as an antique or second-hand article.
  • The supplier does not believe it is being bought to correct sight.

Low Vision Aids

• Same rules apply as optical appliance if designed to correct, remedy, or relieve a defect of sight.

Registered Practitioners and Optical Appliances

• Optometrists, Dispensing Opticians, and Doctors can sell any optical appliance:
  • no need for a valid prescription.
  • no restriction on age.
  • can sell to people registered sight impaired or severely sight impaired.
• Anyone can sell any optical appliance if the sale is done under the supervision of a registered practitioner.

Dispensing - Definition

• Defined by GOC Fitness to Practice Committee as the process of:
  1. Choosing frames.
  2. Taking measurements.
  3. Adjusting the frame.
  4. Ordering.
  5. Checking power & fit – adjusting as necessary.

Dispensing and Supervision

• Where a registered practitioner is supervising a “sale” of spectacles, the supervision must apply to the:
  • dispensing.
  • sale and supply.
  • any re-supply.

Coptom on Sale and Supply

• - General advice
• - Prescriptions over 2 years old
• - Supervision
• - Remote dispensing
• - Advice for patients
• - Ready-made reading spectacles

NHS Optical Vouchers

• NHS Optical vouchers are provided to eligible groups to use towards the cost of specs.
• Can be issued to an eligible person in GOS or HES:
  • After a sight test.
  • Lost or broken specs (u16).
• Voucher values determined by prescription and any clinically necessary extras.
• Reviewed every April by the department of health and social care (England) or Welsh government.

Issuing Optical Vouchers

• 1. Maximise value by transposing prescription to reflect the highest sphere power.
• 2. Issue voucher immediately after a sight test if eligible.
• 3. You can issue a voucher later if the patient becomes eligible (in Wales).
• 4. Patients may use their voucher towards:
  • Complete spectacles.
  • Spectacle lenses to own frame.
  • Contact lenses.

Claiming Payment from NHS

• You must claim either the voucher value or the private cost (if it is lower) from the NHS.
• You may submit a voucher to the NHS for payment after a patient has died or if the patient fails to collect the glasses.
• You must keep full records of the dispense, sale and supply, and repairs for Post-Payment Verification (NHS audit of your claims).

Making Spectacles

• If you make spectacles in your practice, it must be registered with the Medicines Healthcare Products Regulatory Agency (MHRA) for the “assembly” of spectacles (Medical Devices Regulations 2002).
  • That is the act of putting together lenses and frames to make complete spectacles.

Buying Spectacles

• Patients can buy spectacles from the supplier of their choice.
• You cannot make purchasing specs from you a condition of the sight test.

Working in Practice

• In England and Wales, you can be:
  • Self Employed as:
    • A practice owner
    • A locum
  • Employed
    • Working at a multiple or independent

Practice Owner

• • Buy an existing practice
• • Buy-in to an existing practice
• • Start a new practice
• ✓Research the market
• ✓Develop and plan
• ✓Find partners and suppliers
• ✓Setup business
• ✓Get funding

Legal Structures

• Most UK businesses are:
  • Sole traders
  • Limited companies
  • Partnerships

Buying / Buying into Existing Practice

• • Research market
• • Check historic accounts
• • Consider sale price and current profitability
• • Consider active patient base
• • Check for outstanding issues
• • Develop and plan
• • Get independent professional advice

Locum Work

• Technically, a person standing in for someone else
• Getting work:
  • Usually through recommendations
  • Apps
  • Contacting practices directly
  • Agencies
• Try to get a locum contract

Employed Optometrist

• Commonly get work through:
  • Recommendation
  • Applying directly to practices
  • Recruitment agencies
  • Online / Magazine adverts
• Get an employment contract

Optometry Practice - Laws and Regulations

• Similar to all other shops and businesses
• Advertising
  • The Advertising Standards Authority (ASA) regulates all advertising through advertising codes of practice
  • The GOC requires registrants to ensure that advertising and publicity comply with appropriate codes of practice

Consumer Credit

• Financial Services and Markets Act 2000 requires businesses that offer goods or services on credit to be authorized and/or registered with the Financial Conduct Authority.
• Offering credit without being authorized and/or registered is a criminal offense… and if your customer fails to make the required payments, you cannot enforce the agreement.
• The requirement does not apply if ✓the number of payments does not exceed 4 and ✓the period of credit does not exceed 12 months and ✓no interest or other charges are made

Distance Selling

• The Consumer Contracts (Information, Cancellation and Additional Charges) Regulations 2013
• apply to contracts for goods or services to be supplied to a consumer where the contract is made exclusively by means of distance communication
• apply to the sale of spectacles and contact lenses over the internet or by telephone apply to ‘off-premises’ contracts, e.g. domiciliary visits

Employment Law

• Terms and conditions of employment minimum wage, holidays, sick pay, maternity pay, notice
• Transfer of employment when a business is bought or sold
• Disputes between employers and employees disciplinary and employment tribunals
• Protected disclosures criminal offense committed, legal obligation not met, health or safety endangered Work and employment law advice | Acas

Equality Act 2010

• ▪ Protects people against discrimination, harassment or victimisation in respect of protected characteristics
• ▪ Duties apply to staff and patients
• ▪ Must make ‘reasonable adjustments’

Health & Safety, Insurance & Liability

• Buildings, Contents, Business Community
• Employer’s liability, Public liability
• Governed mainly by Health and Safety at Work Act 1974 Controls risks to persons at work and other persons in connection with the activities of persons at work

Music and Television

• The Copyright, Designs and Patents Act 1988 governs the playing of copyright music in public such as:
  • Music in the waiting area
  • Music on a telephone system
• Licences from Performing Rights Society and Phonographic Performance Limited
• TV license is required if any receiving equipment is in the practice

Goods and Services - Consumer Rights

• The Consumer Rights Act 2015 says goods must be:
  • Of satisfactory quality
  • Fit for purpose
  • As described
• Consumers have a right to reject goods that do not meet this within 30 days for a full refund
• Services must be provided:
  • -With reasonable care and skill
  • -In a reasonable time (no specific time in the contract)
  • -For a reasonable charge (if no price agreed in the contract)
    Consumers have the right to have any element of the service that does not meet this re-done at no extra cost

Sunday Trading

• Small shops (up to 280 square meters) can open at any time
• Large shops
  • Can open on Sundays only for 6 consecutive hours between 10 am and 6 pm
  • Must close on Easter Sunday
  • Must close on Christmas Day
  • Must display their restricted Sunday trading hours inside and outside the shop

Taxation

• Tax Wide-ranging legislation administered by HM Revenue & Customs including:
• For individuals
  • Income tax
  • National insurance
• For employers
  • PAYE
• For businesses
  • Value Added Tax (VAT)
  • Corporation Tax

Waste Management

• All waste producers must ensure their waste is disposed of correctly
• Records must be kept regarding waste movement
• Usually handled by your waste disposal company.
• You can’t put health care waste in with domestic refuse

Visual Standards & Driving

• Set down by legislation and from guidance from the Secretary of State’s Advisory Panel for Vision Disorders and Driving.
• Road Traffic Act 1988
• Applied by the DVLA - an executive agency of the Department for Transport
• Optometrists do not make decisions on who can / cannot get a driving licence, only the DVLA has this responsibility.
• DVLA website Website of UK Government website - Standards

Group 1 Visual Standards

• Applies to cars and motorcycles (introduced in 1934)
• With specs or CLs (not bioptics in UK)
• Good daylight
• Normally only verified when test is taken and then at age 70
• Criminal offense not to comply
• DVLA must be informed when px aware or made aware of a problem e.g. progressive condition affecting both eyes (glaucoma, cataract, DR, ARMD) – may issue short licence
• Insurance implications

Group 1 Visual Standards - UK Law

• Under UK Law, the only mandatory assessment performed on Group 1 drivers is the number plate test (carried out before taking the practical driving test)
• Pre 01/09/01: Number plate test ($79 x 57mm @ 20.5m$)
• VAs Snellen 6/12 with both eyes open or in the only eye if monocular
• Field requirement (3mm perimetry target @ 0.33m)

New Number Plates (since 01/09/01)

• Crowding effects due to spacing and character width
• Number plate test ($79 x 50mm @ 20m$)
• 3000+ UK drivers failed driving test at number plate test stage over past 5 years
• 800,000 driving with VA below legal requirement

Group 1 Visual Standards - Measurements

• $79.4mm$ at $20.5m$
• $0.22$ deg = $13.3$ min arc
• Visual acuity of 6/12 on Snellen
• DVLA says 6/12 is likely to pass, and 6/24 is likely to fail
• Distance reduced to $12.3 m$ for milk floats and mowing machines

Number Plate Test - Advantages & Disadvantages

• Disadvantages
  • Variation in lighting
  • Symbol design
  • Soiling of number plates
  • Reduced contrast
  • Testing distance
• Advantages
  • Easy to administer (self or otherwise)
  • Can be tested at the site of the incident

Group 2 Visual Standards

• HGVs and passenger carrying vehicles (10+ people)
• 6/7.5 in better eye; at least 6/60 in the worst eye
• Uncorrected acuity no less than 3/60 in each eye
• Absence of diplopia and normal binocular field of view
• Must meet Group 1 visual acuity standardsCorrective power of no more than +8D permitted with specs
• No limit on corrective power with CLsMonocularity not acceptable except under grandfathering rights

Group 2 Grandfather Rights

• Grandfather rights (Section 68 Motor Vehicles Regs. 1996) – those who passed the test before 01/01/97 can drive more vehicles

Group 2 Visual Standards - Requirements

• UK applicants must produce D4 form filled out by GP
• Far superior system than assessing of Group 1 drivers
• Must be renewed every 5 years up to 65 years
• Must be renewed annually over 65
• Visual standards for this group may also be applied to ambulance drivers etc.
• Remains a blurring of occupational and vocational boundaries re. driving licences

Visual Fields and Driving

• Binocular Esterman program (10dB)
• Occasionally monocular Esterman or Goldmann perimetry requested (fixation accuracy taken into account)
• Max of 3 attempts; false-positive scores below 20%
• Insuperable diplopia in the primary position unacceptable (patch or prism is OK but only prism allowed for Group 2)
• Late-onset diplopia due to stroke precludes driving for 1 month
• Exceptional cases are considered
• Monocularity is permitted for Group 1 but a period of adaptation is required if sudden onset

Group 1 Visual Fields Standard

• Minimum standards for the field of vision:
• Horizontal visual field should be at least 120°; the extension should be at least 50° left and right and 20° up and down
• No defects should be present within a radius of the central 20° of fixation
• Goldmann III4e white setting or equivalent
• 3mm target at 0.3m
• Guidance/rules: - Royal College of Ophthalmologists - 2nd EC directive 1991
• Optoms can apply to do this testing for the DVLA by application

Group 1 Visual Fields Acceptable Loss

• For Group 1 licensing criteria, regarded as acceptable central loss:
• Scattered single missed points
• Single cluster of up to 3 adjoining points

Group 1 Visual Fields Unacceptable Loss

• Group 1 licensing criteria, regarded as unacceptable loss:
• Central loss of ‘clusters of 4 or more’ adjoining points significant when wholly or partly within 20° area
• Loss of a cluster of 3 adjoining points up to and including 20° from fixation and additional missed point(s) within the central 20° area
• Any central loss that is an extension of hemianopia or quadrantanopia or of size greater than 3 missed points

Group 2 Visual Fields Standards

• Group 2 licensing criteria, the patient must have:
• Horizontal visual fields of at least 160°, the extension should be at least 70° left and right and 30° up and down
• No defects can be present within a radius of the central 30°
• No other impairment of visual function e.g., no glare sensitivity, contrast sensitivity, or impairment of twilight vision
• DVLA must be told if a patient has an eyesight problem affecting either eye
• Acceptable loss:
  • Single cluster of up to 3 adjoining points (outside central 30°)
  • 3 or less single missed points

Information on Vision Standards

• There are recognised vision standards for specific occupations and/or tasks
• Information on vision standards can be found:
  1. AOP
  2. Employer
  3. Other professional bodies
  4. Internet … ?

Staying Up to Date

• Vision standards often change:Keep up to dateAlways check the latest information

Ethical Considerations

• Should you provide patient information to a third party?✓ Patient’s written permission is required.Keep a record on the patient’s file