physicians must keep complete and accurate records for each patient, including,
but not limited to, case histories, examinations, diagnostic and therapeutic
services, prescriptions, instructions for home therapies, referral
recommendations and any other information required to make the record complete.
Patient records must be sufficiently detailed and legible so that an
appropriate provider could continue care without requiring additional
information and without detriment to the patient. It is unprofessional conduct
to keep incomplete or inaccurate records for a patient.
(2) Retention Schedule: A patient's records
must be kept in an accessible print or electronic format. The records must be
controlled by an Oregon-licensed optometric physician and kept for a minimum of
seven years from the date of the last office visit or pertinent clinical
notation on the record. If a patient is a minor, the records must be kept seven
years or until the patient is 21 years of age, whichever is longer.
(3) When changing practice locations, closing
a practice location, selling a practice or retiring, an optometric physician
must retain patient records for the required amount of time or transfer the
custody of patient records to a doctor of optometry licensed and practicing
optometry in Oregon. Transfer of patient records pursuant to this section of
this rule must be reported to the Board in writing within 14 days of transfer,
but not later than the effective date of the change in practice location,
closure of the practice location or retirement. It is unprofessional conduct
for a doctor of optometry not to retain and release patient records or fail to
transfer the custody of patient records as required in this rule.
(4) Telehealth patient records must be
transferred to an Oregon licensed optometrist at the time the telehealth
provider stops providing patient care in Oregon.
(5) Upon the death or permanent disability of
an optometric physician, the administrator, executor, personal representative,
guardian, conservator or receiver of the former optometrist must notify the
Board in writing of the management arrangement for the custody and transfer of
patient records. This individual must ensure the security of and access to
patient records by the patient or other authorized party, and must report
arrangements for permanent custody of patient records to the Board in writing
within 90 days. Transfer of patient records to another Oregon-licensed
optometric physician must occur within one year of the death or permanent
disability of the optometric physician.
(6) Optometric physicians must provide copies
of records or detailed summaries of records within 14 calendar days of the
written request of the patient or by a person holding a valid release from the
patient (a recommended sample release form is provided in ORS
192.566). The patient may
request all or part of the record. A summary may substitute for the actual
record only if the patient agrees to the substitution.
(7) Optometric records do not include
personal office notes of the optometric physician or personal communications
between referring or consulting physicians.
(8) Optometric physicians must preserve a
patient's records from unauthorized disclosure and may release them only as
authorized by federal and state laws and rules.
(9) Optometric physicians may establish
reasonable charges to patients for copies of their records and for faxing
prescriptions by long distance phone services, or for any unusual mailing or
handling costs per ORS
(10) Optometric physicians must release
copies of patient prescriptions without additional charges and may not withhold
release of patient records or additional copies of prescriptions for lack of
payment for prior services or goods.
Or. Admin. R.
OP 2-1992, f. & cert.
ef. 10-21-92; OP 2-1995, f. 10-31-95, cert. ef. 11-1-95; OPT 2-2002, f. &
cert. ef. 12-18-02; OPT 1-2013, f. & cert. ef. 1-3-13;
2-2014, f. 11-28-14, cert. ef.
3-2014, f. 12-29-14, cert. ef.
8-2017, amend filed 09/19/2017, effective
5-2019, amend filed 12/12/2019, effective
Statutory/Other Authority: ORS 683 & 182
Statutes/Other Implemented: ORS
683.140 & 683.270 &