Optometrists (ODs) keep patient records to facilitate clinical management and ensure continuity of care. These records should be comprehensive, accurate, clear, and made at the time of the examination. The patient record provides a history of patient care, and may contain material such as printed files, images, test results, referral reports, and more.
The optometric practice or the OD providing care owns the patient records. Optometrists must ensure confidentiality is maintained during the collection, storage, use, and disposal of patient records.
Patients have a legal right to examine and copy their records and to control the use and dissemination of the information contained in their records. Patients also have the right to control disclosure of their optometric records to others. For the purposes of health care, optometrists in most jurisdictions can share the patient health record with another health care professional or provide a copy of it. No third party can demand access to patient optometric records except with specific patient consent in writing, or by legal statute, or court order.
If a patient chooses another practice, he or she can give consent for their new practitioner to request relevant clinical information from their records to enable the continuation of their optometric care. A patient can also request a copy of their records to keep themselves. The costs associated with the transfer of information from patient records are the responsibility of the patient.
Optical prescriptions are available to patients following a comprehensive eye examination so that patients can purchase glasses, or initiate a fitting for contact lenses or subnormal vision devices from a licensed dispensing provider. There is no cost associated with this at the time of the eye examination. A valid optical prescription should contain the optometrist’s identification information, the patient’s name and other identification information as needed, the relevant optical information (e.g. sphere, cylinder, axis, prism, add), the issue date of the prescription, the expiry date, and the prescribing optometrist’s signature.[i] There may be a cost for repeat requests for a valid optical prescription after the examination date, or for expired optical prescriptions.
[i] The measurement of inter-pupillary distance (PD) is not part of an eye examination, but is an important part of the dispensing process. As such, it is the responsibility of the licensed professional dispensing the eyewear.