Current through Register Vol. 48, No. 39, March 25, 2024
Subpart 1.
Minimum standards for medical records.
An optometrist licensed in the state must maintain a medical
record for each patient. For each encounter with a patient, the medical record
must:
A. be legible to someone other
than the author, and written in the English language;
B. contain only those terms and abbreviations
that are or should be comprehensible to other health care professionals in the
same or similar specialties;
C.
contain adequate identification of the patient and treating health care
professional;
D. specify the date
the health care was provided;
E.
contain information supporting the decision making, diagnosis, or recommended
treatment plan, which may include the chief complaint or reason for the
encounter; history of present illness; medical, social, or family history;
examinations performed and tests ordered and their findings or interpretations;
counseling offered; concurrent care or transfers of care; or consultations
requested;
F. specify the
prescriptions written or renewed; any medications prescribed, dispensed, or
administered; and the quantity and strength of each;
G. document the patient's progress during the
course of treatment if applicable; and
H. include all patient records received from
other health care providers, if those records formed the basis for a treatment
decision by the optometrist.
Subp. 2.
Storage (Repealed).
Subp. 3.
Storage.
Patient records required by subpart
1 shall be maintained for at
least five years. In the event of closure of a practice, all records from
patient encounters during the previous five years shall be offered to the
individual patients or transferred to another provider after notification of
the new location is made to those individuals.
