Section 17-6409. MINIMUM COMPLETE EXAMINATION

 

6409.1An optometrist shall maintain a record for each patient that accurately reflects the evaluation and treatment of the patient. These records shall be kept for seven (7) years after last seeing the patient or seven (7) years after a minor patient reaches eighteen (18) years of age.

 

6409.2In the absence of good clinical reasons to the contrary as documented in the patient record, an optometrist shall perform the following minimum examination on each patient, record his or her findings in the patient record, and maintain the patient record as required in § 6409.1 of this chapter:

 

(a)Complete case history, including medical conditions and medications;

 

(b)Visual acuity including:

 

(1)Monocular and binocular; and

 

(2)Aided or unaided;

 

(c)External examination, including pupil reactivity;

 

(d)Internal examination;

 

(e)Subjective refraction to test visual acuity at distance and near;

 

(f)Measurement of binocularity and ocular motility;

 

(g)Tonometry, on patients twelve and older or as needed in the professional opinion of the optometrist;

 

(h)Documentation of treatment, diagnosis; recommendations and directions to the patients, including prescriptions; and

 

(i)Documentation in the patient chart of the name of attending optometrist.

 

6409.3In addition to the requirements set forth in § 6409.1, an optometrist may perform the following tests as part of a minimum examination:

 

(a)Retinoscopy or equivalent; and

 

(b)Color vision screening.

 

6409.4In addition to the requirements set forth in § 6409.1, a contact lens examination, excluding a follow-up exam; shall include at a minimum the following:

 

(a)Assessment of corneal curvature;

 

(b)Assessment of acuity through the contact lens;

 

(c)Directions for the care and handling of lenses and an explanation of the implications of contact lenses with regard to eye health and vision;

 

(d)Assessment of contact lens fit; and

 

(e)Documentation of contact lenses used in fitting procedures.

 

source

Final Rulemaking published at 55 DCR 12043 (November 21, 2008).