22 Tex. Admin. Code § 277.7 - Patient Records
(a) In order to
protect the patient's health, an optometrist or therapeutic optometrist shall
create and maintain a legible and accurate written patient record for each
patient. Every patient record shall provide sufficient information such that:
(1) another optometrist or therapeutic
optometrist can identify the examination performed and the results obtained,
and
(b) This rule is adopted to assist the Board
in determining whether a licensee has complied with the requirements of
Optometry Act § 351.353, Initial Examination of Patient. This rule is not
adopted to establish a standard of care for the practice of
optometry.
(c) Notations to a
detailed preprinted checklist are acceptable if the results of an examination
may clearly and accurately be presented in this format. The use of a check mark
or similar minimal notation to record the performance of an examination, if not
made to a detailed checklist, does not meet the requirements of subsection (a)
of this section. Any patient record that is created or maintained in an
electronic format must have the capability of printing a paper record that
meets the requirements of this rule.
(d) The patient record for each initial
examination for which an ophthalmic lens prescription is signed shall contain,
at a minimum, written notations recording the procedures and findings required
by §§
279.1
and
279.3 of
this title, and Optometry Act § 351.353, in the following format:
(1) An accurate identification of the
patient;
(2) The date of the
examination;
(3) The name of the
optometrist or therapeutic optometrist conducting the examination;
(4) Past and present medical history,
including complaint presented at visit;
(5) A numerical value of the monocular
uncorrected or monocular corrected visual acuity in a standard acceptable
format;
(6) The results of a
biomicroscopic examination of the lids, cornea, and sclera;
(7) The results of the internal examination
of the media and fundus, including the optic nerve and macula, all recorded
individually;
(8) The results of a
retinoscopy. A tape from an automatic refractor is acceptable;
(9) The subjective findings of the
examination. A tape from a computer assisted refractor/photometer is acceptable
if the instrument is being used to obtain subjective findings;
(10) The results of an assessment of
binocular function, including the test used and the numerical endpoint
value;
(11) The amplitude or range
of accommodation expressed in numerical endpoint value including the test used
in the examination;
(12) A
tonometry reading including the type of instrument used in the examination;
and
(13) Angle of vision: the
extent of the patient's field to the left and right.
Notes
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