The European Council of Optometry andOpticsThe European Diploma inOptometry

Portfolio of ClinicalExperience

Candidate’sName

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Date ofSubmission

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(March 2014version)

The Portfolio of ClinicalExperience

ThePortfolioistherecordoftheclinicalexperiencegainedbycandidatesforthe European Diploma in Optometry either during theirundergraduateeducationandtrainingorasapostgraduateoracombinationofthetwo.ThepurposeofthePortfolioistopresentevidenceofthequantity,diversityandquality of care that the candidate provides forpatients.

The European Diploma cannot be awarded until the Portfolio hasbeensatisfactorilycompleted.

Completing thePortfolio

Before starting to complete the Portfolio you should carefully readtheaccompanying document “Guidance for Candidates and Examiners”. Thissetsout the numbers of full eye examinations required from the last two yearsandthesmallernumberofdetailedpatientrecordsthatyouaretosubmit.Italsoexplains the content and format required for these caserecords.

National Data Protection and PrivacyLegislation

Inordertocomplywithdataprotectionandconfidentialitylawsyoushouldensure that you have the patients’ consent to use the records. Also observetheprivacy regulations in your country of practice. The patient should NOTbeindentifiedbynameoraddressbutbyauniquereferencenumberthatwillpermit the original record to be retrieved if requested by theExaminer.

FurtherInformation

If after reading the “Guidance for Candidates and Examiners” you haveanyfurther questions regarding the completion of the Portfolio you shouldcontactthe Secretariat for the Diploma at the ZVA(

Section 1: CandidatesDetails

Name
Address
e-mail
Contact phonenumber

a)European Diploma byexamination

Candidatenumber
Date and examination centre of completing all the writtenandpractical examinations of the EuropeanDiploma.

b)Diploma by accreditation of the European DiplomaExaminations

Name of accreditedprogramme
Name of traininginstitution
Address of traininginstitution
Period ofstudy
Full or Partial accreditation oftheEuropean Diploma Examinations*
If partial accreditation, list the Partsandor Sections of the EuropeanDiplomaExamination that have beenaccredited.
Date of completing thenon-accreditedwritten and practical sections oftheEuropean DiplomaExamination.

*IfthequalificationisonlypartiallyaccreditedthecandidatewillberequiredtotaketheDiploma examination in the sections not accredited before submitting thePortfolio.

c)Diploma by accreditation of the all European Diploma ExaminationsbutNOT the patient experience requirements of thePortfolio.

Name of accreditedprogramme
Name of traininginstitution
Address of traininginstitution
Period of study at theinstitution

Section 2: Evidence of ClinicalExperience

Number of months/years in practiceas:
A qualifiedoptometrist
A qualifiedoptician

Evidence available to supportthis:

*Nationalcertificate / Yes / No
*ProfessionalDiploma
*A certified copy of these certificates should be sent with theapplication

Number of patients examined during the last two years ofcareer

Eyeexaminations
Ophthalmicdispensing
Contact Lens fittingsRGP
Soft
Referrals for ocularabnormalities
Patients seen in hospital or eyeclinic
EvidenceAvailable:
Practicerecords
Training institutionrecordsPersonallogbook / Yes / No

Section 3: Evidence of Scope ofPractice

Please attach copies of twenty patient records that demonstrate that your scope ofpracticematches that of the EuropeanDiploma.

Recordsrequired:

  • 5 primary care eye examinations to include atleast:

2 binocular visionanomalies

1 low vision case

1 paediatric case (for this purpose paediatric is 12 years orunder)

  • 5 abnormal ocular condition cases to include atleast:

3 referrals

  • 5 contact lens cases to include atleast:

1 RGP fitting

  • 5 Dispensings to include a range of different frame and lenstypes

Inadditionyoushouldincludedetailsofthepracticeswherethisexperiencewasgained,together with the name and contact details of any professional colleagues who canprovidereferences confirming the dates during which the experience was gained together,ifpossible, with references confirming your scope ofpractice.

Section 4: Certificate to be completed by thecandidate:

I CERTIFY that the information in this Portfolio is correct and theclinicalexperience claimed can be substantiated by clinical records and thattheserecordscanbemadeavailableifrequiredbytheBoardofExaminersoftheEuropeanDiploma.

Signed

Date

Certificate(s) to be completed by eye careprofessionals

I CERTIFYthatwas a student/colleague/employeefrom

toand has undertaken the eye examinations listedin

this Portfolio from

to

and that to the best ofmy

knowledge has worked to the standards required by the EuropeanDiploma.

Signed

Date

FullName

Qualification

Address

PhoneNumber

e-mailaddress

Aseparatecertificateshouldbecompletedforeachperiodofexperienceatatraining institution, in an optometric practice or an ophthalmologyclinic.

EUROPEANDIPLOMAPORTFOLIOPATIENTRECORD

NAMEANDADDRESSOFCLINIC/PRACTICE/INSTITUTION*

NAME OFEMPLOYER/SUPERVISORDATES OFEMPLOYMENT

DATE / PATIENTREFERENCE / REFRACTIONPRESBYOPEAGE / REFRACTION
PRE-PRESBYOPEAGE / REFRACTIONCHILDAGE / OCULARABNORMALITY / CONTACTLENSES / LOW VISIONPATIENT / DISPENSE
(tick thebox)
SV -SingleVision
BF -BifocalVF -Varifocal / INSTILLATION OFDRUGS
(Type)
C -CataractA -ARMD
D-Diabetes
G -GlaucomaO -Other
Tick thebox / Detail ofOtherAbnormalities / RGP
Newfit(Type) / RGP
A/C / SOFT
Neffit(Type) / SOFT
A/C / BINOCULARVISIONABNORMALITY(Type)
C / A / D / G / O / SV / BF / VF
Total

*USEASEPARATESHEETFOREACHCLINIC/PRACTICE/INSTITUTION