Patient Care Standards, Recordkeeping, and Informed Consent
Standard of care
The Board expects optometrists to provide care consistent with the statutory scope and accepted optometric standards. A comprehensive examination generally includes history, visual acuity, refraction, binocular assessment, ocular health evaluation, tonometry when indicated, and dilation when clinically appropriate. If findings exceed the optometrist’s scope or competence, the patient must be referred.
Informed consent
Consent must be informed and documented. The optometrist should explain the diagnosis, proposed treatment, material risks and benefits, reasonable alternatives, and the consequences of refusal. This is especially important for dilation, contact lens prescribing, therapeutic drugs, and any procedure with meaningful risk. Consent may be oral or written, but the record should show what was discussed.
Recordkeeping
Records should be legible, contemporaneous, dated, and complete enough for another provider to understand the care. Include history, findings, diagnosis, treatment plan, prescriptions, referrals, and consent or refusal. Corrections should be clearly identified, not obliterated. Patients have access rights under the Minnesota Health Records Act, Minn. Stat. §§ 144.291–.298, and retention must follow Board requirements and applicable law.
Worked example
A patient with sudden floaters declines dilation because of driving concerns. The optometrist explains the risk of missing a retinal tear, documents the discussion and refusal, offers a return visit or referral, and records the advice. If the patient later has a poor outcome, the note supports that informed refusal was honored rather than ignored.
Traps
“If it is not documented, it did not happen” is a practical discipline risk. Do not record only a diagnosis without supporting findings. Do not obtain consent by signature alone without evidence of discussion. Do not alter a record after a complaint without following proper amendment rules.