Section 3.02 - Patient Records(1)Required Contents. An Optometrist shall establish and maintain an adequate, legible, and accurate written or electronic case record for each patient. Such case records shall be maintained for a period of not less than seven years from the date of the patient's last visit. Provided, however, that in the case of minor patients, the case records shall be maintained for a period of not less than seven years from the date of the patient's last visit or until the minor patient reaches 18 years of age, whichever is longer. Each case record shall, at a minimum, contain all of the following information:(a) The name, address, telephone number, and date of birth of the patient to whom the record pertains;(b) The date of each examination or patient procedure, and the results of all procedures performed at each such examination or patient procedure;(c) The date of each contact lens evaluation performed, and the results of all procedures performed at each such contact lens evaluation, including but not limited to all procedures required by 246 CMR 3.01(2);(d) Written documentation of the name and strength of any and all DPAs or TPAs administered to the patient's eye(s) during the course of any vision analysis, contact lens evaluation or other examination;(e) Any and all information concerning prescriptions written for the patient; and(f) Diagnosis, treatment, and recommended management.(2)Confidentiality of Records. (a) An Optometrist shall keep in confidence whatever the Optometrist may learn about a patient during the course of the patient's diagnosis, evaluation, treatment, and care.(b) Information provided to the Optometrist shall be divulged only when such disclosure is authorized in writing by the patient or his/her authorized representative, or is otherwise required by applicable state or federal laws and/or regulations.(3)Patient Access to Records.(a) An Optometrist shall permit inspection of a patient's case record by the patient to whom that record pertains, or by said patient's authorized representative, during his or her regular business hours within a reasonable time not exceeding seven business days.(b) An Optometrist shall not require a patient to sign any waiver or release from liability as a condition for allowing such inspection.(c) An Optometrist shall furnish a copy of a patient's case record to the patient to whom that record pertains, or to the patient's authorized representative, upon request within 30 days.(d) An Optometrist may charge a patient a reasonable fee for the reproduction of said case record.(e) The original copy of the case record shall, in all events, remain the property of the Optometrist.(4)Ophthalmic Lens or Spectacle Eyeglass Prescriptions - Contents.(a) For purposes of 246 CMR 3.02, a "prescription for ophthalmic lenses or spectacle eyeglasses" is defined as a written order bearing the original handwritten or electronic signature of an Optometrist, or an oral order issued directly by an Optometrist, authorizing the provision of specified ophthalmic lenses or spectacle eyeglasses.(b) Said prescriptions shall, at a minimum, contain all of the following information: 1. The name, office address, office telephone number, and registration number of the Optometrist issuing said prescription;2. The name of the patient to whom or for whom the prescription is issued;3. The date on which the prescription is issued and the date on which said prescription shall expire;4. The sphere power, cylinder power and axis, prism power, and position of the base for the ophthalmic lenses or spectacle eyeglasses to be furnished, if applicable;5. The lens material, if clinically significant;6. The interpupillary measurement for distance and/or near as it pertains to the prescription;7. The near add power, if applicable;8. The segment type and size, if applicable;9. The tint or coating, if applicable; and10. Any and all appropriate notations as to when the lenses or spectacle eyeglasses are to be worn.(5)Patient Access to Ophthalmic Lens or Spectacle Eyeglass Prescriptions. An Optometrist shall furnish a copy of a patient's prescription for ophthalmic lenses or spectacle eyeglasses as required by 16 CFR 456; Opthalmic Practice Rules.(6)Contact Lens Prescriptions - Content. For the purpose of 246 CMR 3.02, a "prescription for contact lenses" is defined as a written order bearing the original handwritten or electronic signature of an Optometrist, or an oral order issued directly by an Optometrist, which authorizes the provision of specified rigid or soft contact lenses to a patient.(a) A prescription for rigid contact lenses shall, at a minimum, contain all of the following information:1. The name, office address, telephone number and License number of the Optometrist issuing said prescription;2. The name of the patient for whom the prescription is being issued;3. The date on which the patient was examined, the date of issuance of the prescription (if different), and the date on which the prescription shall expire;4. The lens power of the lenses to be provided;5. The overall diameter of the lens;6. The optic zone diameter of the lens, if applicable;7. The inside base curve radius of the lens;8. The center thickness of the lens, if applicable;9. The lens manufacturer and lens material, if applicable;10. The tint and/or any other special design features, if applicable; and11. Any applicable notations as to when the lenses are to be worn.(b) A prescription for soft contact lenses shall, at a minimum, contain all of the following information: 1. The name, office address, telephone number and License number of the Optometrist issuing said prescription;2. The name of the patient for whom the prescription is being issued;3. The date on which the patient was examined, the name, the date of issuance of the prescription (if different), and the date on which the prescription shall expire;4. The lens power of the lenses to be provided;5. The overall diameter of the lens;6. The base curve radius of the lens, if applicable;7. The lens manufacturer and lens material, or trade name;8. The series of the lens to be provided, if applicable;9. The tint, water content, and/or any other special design features which may be applicable; and10. Any applicable notations as to when the lenses are to be worn.(c) A "prescription for contact lenses" shall not be considered complete until such time as the Optometrist caring for the patient in question, in the reasonable exercise of his or her sound professional judgment, determines that the power, fit, and other characteristics of the lenses are properly tailored to the documented clinical needs of the patient.(7)Access to Contact Lens Prescription Information. An optometrist shall furnish a copy of, or verify, a patient's prescription for contact lenses in accordance with 15 U.S.C., Chapter 102, QQ 7601 through 7610: the Fairness to Contact Lense Consumer Act.(8)Effect of Cessation of Practice. Upon cessation of his or her practice, an Optometrist shall transfer all case records, including all prescription information, which are less than seven years old to a location where such records may be inspected and copied by patients. An Optometrist, upon such cessation of practice, shall immediately notify the Board in writing of the location of such records.Amended by Mass Register Issue 1340, eff. 6/2/2017.