O-7, r. 20 - Regulation respecting the keeping of the optometrical record

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2.02. An optometrist must enter in each record the following data and information:
(a)  the date of the opening of the record;
(b)  the names of the patient at his birth, his address, telephone number, health insurance number, date of birth, sex and, in the case of a married person, the name of his spouse;
(c)  the date of the examination and of the other professional services rendered;
(d)  a summary description of the reasons for the examination and the other professional services rendered;
(e)  the name, place of practice and profession of the professional who referred the patient, should the occasion arise;
(f)  the history of the case;
(g)  the examination he made and other professional services he rendered;
(h)  the ocular pathological condition detected;
(i)  the optometrical diagnosis;
(j)  the recommendations to the patient;
(k)  the treatment prescribed;
(l)  the orthoptic, orthesis or prothesis which was prescribed or furnished, should the occasion arise; and
(m)  the annotations, correspondence and other documents respecting professional services rendered.
R.R.Q., 1981, c. O-7, r. 9, s. 2.02.