Section 338.259. Patient records; referral of patients for care.

Rule 9. (1) Patient records shall contain all of the following information:

(a)   The name of the examining optometrist.

(b)   The chief complaint or reason for the examination.

(c)   The results of each procedure performed.

(d)  The assessment of findings.

(e)     The management disposition, including a referral recommendation,  if appropriate.

(2)  The records shall be retained by the licensee or assignee for not less than 7 years.

(3)     If, in the course of the examination of a patient, an optometrist, in his or her professional judgment, determines the presence of a   condition  that requires evaluation or treatment which is outside the scope of practice of optometry, then it is the professional responsibility of the  optometrist  to refer the patient for further care.

History: 1944 AC; 1954 AC; 1979 AC; 1983 AACS; 1994 AACS; 2010 AACS.