A. An optometrist shall legibly document in a patient record the following:
1. During a routine or medical eye examination:
a. An adequate case history, including the patient's chief complaint;
b. The performance of appropriate testing;
c. The establishment of an assessment or diagnosis; and
d. A recommendation for an appropriate treatment or management plan, including any necessary follow-up.
2. During an initial contact lens examination:
a. The requirements of a routine or medical eye examination as prescribed in subdivision 1 of this subsection;
b. Assessment of corneal curvature;
c. Evaluation of contact lens fitting;
d. Acuity through the lens; and
e. Directions for the wear, care, and handling of lenses.
3. During a follow-up contact lens examination:
a. Evaluation of contact lens fitting and anterior segment health;
b. Acuity through the lens; and
c. Such further instructions as necessary for the individual patient.
4. In addition, the record of any examination shall include the signature of the attending optometrist and, if indicated, refraction of the patient.
B. The following information shall appear on a prescription for ophthalmic goods:
1. The printed name of the prescribing optometrist;
2. The address and telephone number at which the patient's records are maintained and the optometrist can be reached for consultation;
3. The name of the patient;
4. The signature of the optometrist;
5. The date of the examination;
6. If an expiration date is placed on a prescription for ophthalmic goods, the date shall not be less than one year unless the medical reason for a shorter expiration date is documented in the patient record; and
7. Any special instructions.
C. Contact lens.
1. Sufficient information for complete and accurate filling of an established contact lens prescription shall include (i) the power, (ii) the material or manufacturer or both, (iii) the base curve or appropriate designation, (iv) the diameter when appropriate, and (v) medically appropriate expiration date.
2. An optometrist shall provide a patient with a copy of the patient's contact lens prescription at the end of the contact lens fitting, even if the patient does not ask for it. An optometrist may first require all fees to be paid, but only if
he the optometrist requires immediate payment from patients whose eye examinations reveal no need for corrective eye products. Patient confirmation of receipt of the prescription at the end of the contact lens fitting shall be maintained in the patient record.
3. An optometrist shall provide or verify the prescription to anyone who is designated to act on behalf of the patient, including contact lens sellers.
4. An optometrist shall not require patients to buy contact lenses, pay additional fees, or sign a waiver or release in exchange for a copy of the contact lens prescription.
5. An optometrist shall not disclaim liability or responsibility for the accuracy of an eye examination.
D. Spectacle lens.
1. A licensed optometrist shall provide a written prescription for spectacle lenses immediately after the eye examination is completed. He may first require all fees to be paid, but only if he requires immediate payment from patients whose eye examinations reveal no need for corrective eye products.
2. An optometrist shall not require patients to buy ophthalmic goods, pay additional fees, or sign a waiver or release in exchange for a copy of the spectacle prescription.
3. An optometrist shall not disclaim liability or responsibility for the accuracy of an eye examination.
E. Practitioners shall maintain a patient record for a minimum of six years following the last patient encounter with the following exceptions:
1. Records that have previously been transferred to another practitioner or health care provider or provided to the patient or his personal representative; or
2. Records that are required by contractual obligation or federal law to be maintained for a longer period of time.
F. Practitioners shall post information or in some manner inform all patients concerning the time frame for record retention and destruction. Patient records shall only be destroyed in a manner that protects patient confidentiality.
G. For the purpose of prescribing spectacles, eyeglasses, lenses, or contact lenses to a patient, a licensee shall establish a bona fide provider-patient relationship in accordance with requirements of § 54.1-2400.01:2 of the Code of Virginia.