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

Section 2.02 Disposition versions

2012-09-01

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.