49 Pa. Code § 23.71. Patient records.

PROFESSIONAL PRACTICE

§ 23.71. Patient records.

(a)  An optometrist shall use professional judgment to determine what services are to be provided to his patients. Records of the actual services rendered shall be maintained for a minimum of 7 years after the last consultation with a patient. Records must indicate when a referral has been made to a physician. An examination may include the following:
   (1)  Complete history.
   (2)  Uncorrected visual acuity.
   (3)  Detailed report of the external findings.
   (4)  Ophthalmoscopic examination (media, fundus, blood vessels, disc).
   (5)  Corneal curvature measurements (dioptral).
   (6)  Static retinoscopy.
   (7)  Amplitude of convergence and accommodation.
   (8)  Ocular muscle balance.
   (9)  Subjective refraction test.
   (10)  Fusion.
   (11)  Stereopsis.
   (12)  Color vision.
   (13)  Visual fields (confrontation).
   (14)  Visual fields including manual or automated perimetry.
   (15)  Prescription given and visual acuity obtained.
   (16)  Biomicroscopy (slit lamp).
   (17)  Tonometry.
   (18)  Prognosis, stable or unstable.
   (19)  Pharmaceutical agents used or prescribed, including strength, dosage, number of refills and adverse reaction, if applicable.
(b)  An optometrist shall provide a patient with a copy of the patient’s contact lens prescription in accordance with the Fairness to Contact Lens Consumers Act (15 U.S.C.A. § §  7601—7610). An optometrist shall provide a patient with a copy of the patient’s spectacle prescription in accordance with the Federal Trade Commission Ophthalmic Practice Rules (16 CFR 456.1—456.4).

Authority

   The provisions of this §  23.71 issued under section 3(a)(2.1) and (3)(b)(9) and (14) of the Optometric Practice and Licensure Act (63 P.S. §  244.3(a)(2.1) and (3)(b)(9) and (14)).

Source

   The provisions of this §  23.71 adopted October 28, 1988, effective October 29, 1988, 18 Pa.B. 4863; amended June 3, 2005, effective June 4, 2005, 35 Pa.B. 3220. Immediately preceding text appears at serial pages (305101) to (305102).

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