| (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.
|
