Iowa Admin. Code r. 645-182.2 - Recordkeeping
Optometrists will maintain patient records in a manner consistent with the protection of the welfare of the patient. Records will be permanent, timely, accurate, legible, and easily understandable.
(1) Optometrists will maintain optometry
records for each patient. The records will contain all of the following:
a.
Personal data.
(1) Name, date of birth, address and, if a
minor, name of parent or guardian; and
(2) Name and telephone number of emergency
contact.
b.
Optometry and medical history. Optometry records will include
information from the patient or the patient's parent or guardian regarding the
patient's optometric and medical history. The information will include
sufficient data to support the recommended treatment plan.
c.
Patient's reason for
visit. Optometric records will include the patient's stated visual
health care reasons for visiting the optometrist.
d.
Clinical examination progress
notes. Optometric records will include chronological dates and
descriptions of the following:
(1) Clinical
examination findings, tests conducted, and a summary of all pertinent
diagnoses;
(2) Plan of intended
treatment and treatment sequence;
(3) Services rendered and any treatment
complications;
(4) All ancillary
testing, if applicable;
(5) Vision
tests completed and visual acuity;
(6) Name, quantity, and strength of all drugs
dispensed, administered, or prescribed; and
(7) Name of optometrist who performs any
treatment or service or who may have contact with a patient regarding the
patient's optometric health.
e.
Informed consent.
Optometric records will include documentation of informed consent for
procedure(s) and treatment that have potential serious complications and known
risks.
(2) Retention of
records. An optometrist will maintain a patient's record(s) for a minimum of
five years after the date of last examination, prescription, or treatment.
Records for minors will be maintained for, at minimum, one year after the
patient reaches the age of majority (18) or five years after the date of last
examination, prescription, or treatment, whichever is longer.
Proper safeguards will be maintained to ensure the safety of records from destructive elements.
(3) Electronic recordkeeping. The
requirements of this rule apply to electronic records as well as to records
kept by any other means. When electronic records are kept, an optometrist will
keep either a duplicate hard-copy record or a back-up unalterable electronic
record.
(4) Correction of records.
Notations will be legible, written in ink, and contain no erasures or
white-outs. If incorrect information is placed in the record, it must be
crossed out with a single nondeleting line and be initialed by an optometric
health care worker.
(5)
Confidentiality and transfer of records. Optometrists will preserve the
confidentiality of patient records in a manner consistent with the protection
of the welfare of the patient. Upon request of the patient or the patient's new
optometrist, the optometrist will furnish such optometry records or copies of
the records as will be beneficial for the future treatment of that patient. The
optometrist may include a summary of the record(s) with the record(s) or copy
of the record(s). The optometrist may charge a nominal fee for duplication of
records, but may not refuse to transfer records for nonpayment of any fees. The
optometrist may ask for a written request for the record(s).
(6) Retirement or discontinuance of practice.
A licensee, upon retirement, or upon discontinuation of the practice of
optometry, or upon leaving a practice or moving from a community, will notify
all active patients in writing, or by publication once a week for three
consecutive weeks in a newspaper of general circulation in the community, that
the licensee intends to discontinue the practice of optometry in the community,
and will encourage patients to seek the services of another licensee. The
licensee will make reasonable arrangements with active patients for the
transfer of patient records, or copies of those records, to the succeeding
licensee. "Active patient" means a person whom the licensee has examined,
treated, cared for, or otherwise consulted with during the two-year period
prior to retirement, discontinuation of the practice of optometry, or leaving a
practice or moving from a community.
(7) Nothing stated in these rules will
prohibit a licensee from conveying or transferring the licensee's patient
records to another licensed optometrist who is assuming a practice, provided
that written notice is furnished to all patients.
Notes
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No prior version found.