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

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chapter O-7, r. 20
Regulation respecting the keeping of the optometrical record
OPTOMETRISTS — OPTOMETRICAL RECORD
Optometry Act
(chapter O-7, s. 3).
O-7
Professional Code
(chapter C-26, s. 91).
C-26
September 1 2012
DIVISION I
GENERAL PROVISIONS
1.01. The Interpretation Act (chapter I-16) applies to this Regulation.
R.R.Q., 1981, c. O-7, r. 9, s. 1.01.
1.02. Nothing in this Regulation shall be interpreted as excluding the use of data or any other technique for the constitution and keeping of the optometrical record.
R.R.Q., 1981, c. O-7, r. 9, s. 1.02.
DIVISION II
OPTOMETRICAL RECORD
2.01. Subject to section 2.07, an optometrist must keep, at the place where he practises his profession, a record for each of his patients.
R.R.Q., 1981, c. O-7, r. 9, s. 2.01.
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.
2.03. An optometrist must keep each record up-to-date up to such time as he shall cease to render professional services to the person concerned by such record.
R.R.Q., 1981, c. O-7, r. 9, s. 2.03.
2.04. An optometrist must keep each record for at least 5 years effective from the date of the last service rendered.
R.R.Q., 1981, c. O-7, r. 9, s. 2.04.
2.05. An optometrist must keep his records in a room or cabinet which is not easily accessible to the public and which may be locked.
R.R.Q., 1981, c. O-7, r. 9, s. 2.05.
2.06. Where a document has been withdrawn from the record, the optometrist must enter a note in such record indicating the nature of the document and the date of withdrawal.
R.R.Q., 1981, c. O-7, r. 9, s. 2.06.
2.07. Where an optometrist is a member of or is in the employ of a partnership, or where he is in the employ of a natural or legal person, the records kept by the partnership or employer respecting the persons concerned by the services which such optometrist renders shall be considered, for the purposes of this Regulation, as the records of the latter if he may enter the data or information mentioned in section 2.02 therein; if he may not do so, he must keep a record for each of these persons.
Where an optometrist practises in an institution within the meaning of the Act respecting health services and social services (chapter S-4.2) and the Act respecting health services and social services for Cree Native persons (chapter S-5) the recipient’s record within the meaning of this Act and its regulations shall be considered, for the purposes of this Regulation, as the record of such optometrist if he may enter or cause to enter therein, in the form of a report or otherwise, the information mentioned in section 2.02; in such case, the optometrist need not comply with sections 2.04 to 2.06.
The optometrist must sign or initial every entry or report he enters in a record in accordance with the first and second paragraphs.
R.R.Q., 1981, c. O-7, r. 9, s. 2.07.
REFERENCES
R.R.Q., 1981, c. O-7, r. 9