Guidance for Practices & Practitioners: Accurate Recording of Outcomes
22 May 2026
Dear Colleague,
This email outlines the importance of accurately recording episodes and outcomes in OPERA, ensuring follow-ups and referrals are logged correctly to support clear patient pathways and reliable service data.
Recording Guidance for Practices and Practitioners:
We would like to remind all practices and practitioners of the importance of recording episodes accurately and consistently. Accurate recording is essential to ensure patient pathways are clear, outcomes are correctly represented, and service data can be interpreted reliably.
Recording Episode Types Correctly:
In Community Urgent Eyecare Services (CUES), for example, it is important that follow‑up appointments are recorded as follow ups, rather than being added to the system as additional telemedicine or face to face episodes.
While we recognise that patients may flow through CUES in different ways depending on clinical need, it is crucial to record accurately whether an interaction represents a new episode or a follow up to an existing episode.
In general, there should not be multiple episodes of the same type recorded for the same patient where these represent continuation of care rather than a new presentation. We have identified cases where multiple telemedicine or face to face episodes have been recorded, when follow ups would have been more appropriate.
Example:
If a patient pathway is as follows
- Telemedicine assessment
- Face to face appointment
- Further face to face review
This should be recorded as:
Telemedicine → Face to face → Follow up rather than multiple face to face episodes.
Similarly, where a patient is referred to your practice appearing on your clinical dashboard, the Face-to-Face consultation should continue on the same record using the same OPR number. A new record should not be created.
Guidance on accepting referrals can be found here Internal Referrals – OPERA
Accurate episode type recording ensures that follow ups are recognised correctly and avoids misrepresentation of activity.
Recording Outcomes Accurately:
It is essential that outcomes recorded in Opera accurately reflect the outcome for the patient.
We have identified examples where an episode has been recorded as discharged, but the written clinical notes indicate that the patient was referred outside Opera, this may happen for a number of reasons.
Local protocols may require referrals to be sent via another route in certain circumstances. For example, in an Emergency or where another EeRS platform is used to transfer information. This is a local variation and not the usual route for referral.
Guidance on how to correctly process these referrals can be found here:
Under no circumstances should an episode be closed and a referral made using a GOS 18 referral on OPERA, where this is done the referral will be rejected back to you from the Eyecare Navigation Service and you will be instructed to refer via the original service record e.g. in CUES or GERS.
In all cases, where a referral has been made outside Opera, the episode outcome should clearly reflect this. Discharge should only be selected where the patient has genuinely been discharged from care with no onward referral.
Why this matters:
Accurate recording
- Supports patient safety and continuity of care
- Improves the quality and reliability of service reporting
- Reduces the need for retrospective clarification and follow up
Further guidance including recording of different episode types can be found in the relevant service guides located on OPERA help pages Service Guides for Practices and Practitioners – OPERA
Thank you for your continued support in maintaining high standards of delivery.
Kind regards,
Primary Eyecare Services
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