OAR 852-010-0051: Records

(1) Optometric physicians must keep complete and accurate records for each patient, including, but not limited to, case histories, examinations, diagnostic and therapeutic services, prescriptions, instructions for home therapies, referral recommendations and any other information required to make the record complete. Patient records must be sufficiently detailed and legible so that an appropriate provider could continue care without requiring additional information and without detriment to the patient. It is unprofessional conduct to keep incomplete or inaccurate records for a patient. (2) Retention Schedule: A patient’s records must be kept in an accessible print or electronic format. The records must be controlled by an Oregon-licensed optometric physician and kept for a minimum of seven years from the date of the last office visit or pertinent clinical notation on the record. If a patient is a minor, the records must be kept seven years or until the patient is 21 years of age, whichever is longer. (3) When changing practice locations, closing a practice location, selling a practice or retiring, an optometric physician must retain patient records for the required amount of time or transfer the custody of patient records to a doctor of optometry licensed and practicing optometry in Oregon. Transfer of patient records pursuant to this section of this rule must be reported to the Board in writing within 14 days of transfer, but not later than the effective date of the change in practice location, closure of the practice location or retirement. It is unprofessional conduct for a doctor of optometry not to retain and release patient records or fail to transfer the custody of patient records as required in this rule. (4) Telehealth patient records must be transferred to an Oregon licensed optometrist at the time the telehealth provider stops providing patient care in Oregon. (5) Upon the death or permanent disability of an optometric physician, the administrator, executor, personal representative, guardian, conservator or receiver of the former optometrist must notify the Board in writing of the management arrangement for the custody and transfer of patient records. This individual must ensure the security of and access to patient records by the patient or other authorized party, and must report arrangements for permanent custody of patient records to the Board in writing within 90 days. Transfer of patient records to another Oregon-licensed optometric physician must occur within one year of the death or permanent disability of the optometric physician. (6) Optometric physicians must provide copies of records or detailed summaries of records within 14 calendar days of the written request of the patient or by a person holding a valid release from the patient (a recommended sample release form is provided in ORS 192.566). The patient may request all or part of the record. A summary may substitute for the actual record only if the patient agrees to the substitution. (7) Optometric records do not include personal office notes of the optometric physician or personal communications between referring or consulting physicians. (8) Optometric physicians must preserve a patient’s records from unauthorized disclosure and may release them only as authorized by federal and state laws and rules. (9) Optometric physicians may establish reasonable charges to patients for copies of their records and for faxing prescriptions by long distance phone services, or for any unusual mailing or handling costs per ORS 192.521 (10) Optometric physicians must release copies of patient prescriptions without additional charges and may not withhold release of patient records or additional copies of prescriptions for lack of payment for prior services or goods.