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RULE §277.7Patient Records

(a) In order to protect the patient's health, an optometrist or therapeutic optometrist shall create and maintain a legible and accurate written patient record for each patient. Every patient record shall provide sufficient information such that:

  (1) another optometrist or therapeutic optometrist can identify the examination performed and the results obtained, and

  (2) the Board can accurately assess a licensee's compliance with §§279.1 and 279.3 of this title, and Optometry Act §351.353.

(b) This rule is adopted to assist the Board in determining whether a licensee has complied with the requirements of Optometry Act §351.353, Initial Examination of Patient. This rule is not adopted to establish a standard of care for the practice of optometry.

(c) Notations to a detailed preprinted checklist are acceptable if the results of an examination may clearly and accurately be presented in this format. The use of a check mark or similar minimal notation to record the performance of an examination, if not made to a detailed checklist, does not meet the requirements of subsection (a) of this section. Any patient record that is created or maintained in an electronic format must have the capability of printing a paper record that meets the requirements of this rule.

(d) The patient record for each initial examination for which an ophthalmic lens prescription is signed shall contain, at a minimum, written notations recording the procedures and findings required by §§279.1 and 279.3 of this title, and Optometry Act §351.353, in the following format:

  (1) An accurate identification of the patient;

  (2) The date of the examination;

  (3) The name of the optometrist or therapeutic optometrist conducting the examination;

  (4) Past and present medical history, including complaint presented at visit;

  (5) A numerical value of the monocular uncorrected or monocular corrected visual acuity in a standard acceptable format;

  (6) The results of a biomicroscopic examination of the lids, cornea, and sclera;

  (7) The results of the internal examination of the media and fundus, including the optic nerve and macula, all recorded individually;

  (8) The results of a retinoscopy. A tape from an automatic refractor is acceptable;

  (9) The subjective findings of the examination. A tape from a computer assisted refractor/photometer is acceptable if the instrument is being used to obtain subjective findings;

  (10) The results of an assessment of binocular function, including the test used and the numerical endpoint value;

  (11) The amplitude or range of accommodation expressed in numerical endpoint value including the test used in the examination;

  (12) A tonometry reading including the type of instrument used in the examination; and

  (13) Angle of vision: the extent of the patient's field to the left and right.

Source Note: The provisions of this §277.7 adopted to be effective June 18, 2001, 26 TexReg 4477

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