Section R4-21-305. Recordkeeping

A.       A licensee shall create and maintain a complete and legible record of each examination including all findings. A licensee shall ensure that a patient record is maintained for at least six years after the licensee’s last contact with the patient and includes:

1.        Patient’s name and contact information;

2.        Date on which an entry is made in the patient’s record;

3.        Identification  of  the  person  making  the  entry  in  the patient’s record;

4.        Complete health history;

5.        Visual acuity of each eye: entering and best corrected;

6.        Ocular health examination;

7.        Assessment of intraocular and extra-ocular muscle func- tion;

8.        Objective or subjective refraction of the eyes;

9.        Diagnosis, treatment, and disposition;

10.      Type and dosage of each use of a pharmaceutical agent;

11.      Final optometric prescription given, if any;

12.      Corrective procedure program prescribed, if any; and

13.      Signature of licensee providing diagnosis, treatment, and disposition.

B.       A licensee may create and maintain any record required under

A.R.S. Title 32, Chapter 16 or this Chapter in electronic for- mat. A licensee may convert any record maintained under

A.R.S. Title 32, Chapter 16 or this Chapter to electronic for- mat. A licensee who converts a record to electronic format shall ensure that the record contains all the information required under A.R.S. Title 32, Chapter 16 and this Chapter.

C.       A licensee who discontinues practice for any reason shall arrange for a patient’s record to be available to the patient for six years from the date the licensee discontinues practice. Before discontinuing practice, a licensee shall notify the Board of the location at which patient records from the practice will be maintained.

D.       A licensee who acquires the patient records of a licensee who discontinued practice, either with or without succeeding to the practice of the other licensee, shall ensure that the records are available to the patients for six years after the licensee from whom the records were acquired discontinued practice.

E.       A licensee shall provide a tangible or electronic copy of a patient’s record within five business days after receiving a written request from the patient. The licensee shall provide the copy to any person designated by the patient. The licensee may charge a fee to cover the costs of providing the copy. The licensee shall maintain a record of providing the copy for six years.

F.        Regardless of the form in which a licensee creates and main- tains patient records, the licensee shall comply with all law regarding security, confidentiality, and release of the records.

Historical Note

Adopted effective April 1, 1991 (Supp. 91-2). Amended

effective November 5, 1998 (Supp. 98-4). Amended by

final rulemaking at 11 A.A.R. 1864, effective May 3, 2005 (Supp. 05-2). Former R4-21-305 renumbered to R4- 21-306; new R4-21-305 renumbered from R4-21-304 and amended by final rulemaking at 14 A.A.R. 12, effective February 2, 2008 (Supp. 07-4).