RULE 069.00.03-001 - Article VI: Section R - Patient Records

RULE 069.00.03-001. Article VI: Section R - Patient Records

Any optometrist who examines a patient and creates a record of said patient is responsible for the security and custody of said record. Because of the confidential nature and relationship between the examining optometrist and patient, the examination record (including the patient's name, address, age, occupation, and findings and pertinent facts) discovered and disclosed during the course of such examination, as well as the record of professional services rendered and fees charged therefore, shall be the exclusive property of the optometrist who rendered the professional services to said patient. Patient records described aforesaid are the property and responsibility of the examining optometrist, except when the examining optometrist is employed by an optometrist or ophthalmologist. In this circumstance, the patient records are the property and responsibility of the optometrist or ophthalmologist who employs the optometrist. If an optometrist is not employed by an optometrist or ophthalmologist and temporarily take the place of an optometrist, then any records created by him shall be removed and secured by him at the completion of that day's practice.

Access to patient records is available only to the optometrist who created the record, the optometrist or ophthalmologist who employs the optometrist, the patient (or the person designated by the patient in writing to see said records) or employees under the direct personal supervision and control of said optometrist, or to those individuals or entities authorized by law or Federal Regulation to receive the same. Any optometrist, who is the custodian of a patient record and ceases to practice at a particular location, must notify said patient where his or her personal record may be obtained. Before any record of a patient is destroyed, said patient must be notified prior to his or her record being destroyed and given thirty (30) days to respond before said record is destroyed. However, if a patient has not been examined for five (5) years or more, said patient's record may be destroyed by the examining optometrist without notifying said patient.

Any patient is entitled to a copy of his or her patient records and may request the same. If the patient makes a request in writing to the optometrist, requesting said records and designating where said record is to be sent and to whom, the optometrist is to copy and make the record available at a reasonable fee, excluding x-rays, not exceed one dollar ($1.00) per page for the first five pages and twenty five cents ($.25) for each additional page, except that a minimum charge may be five dollars ($5.00) provided, however, a reasonable recovery fee for stored records may be added to the photocopying charge. Provided, further, this section shall not prohibit reasonable fees for a narrative report or medical review of a record when performed by the optometrist subject to the request.

If an optometrist renders treatment to a patient in a hospital or nursing home, he may elect to utilize the record keeping system of the facility, if he determines that it is accurate and secure and can be available to him or the patient.

It is unprofessional conduct to not comply with this regulation, that is for an optometrist not to properly secure, store and protect the privacy of a patient record and to not distribute copies of those said records to the patient or to the person designated by the patient when requested by the patient.

(7/17/2003)

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