49 Pa. Code § 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).
Notes
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)).
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