Standards of Practice: Records, Consent, Abandonment, Referral, and Co-Management
Standards-of-practice questions test whether the chart and the patient relationship would satisfy the Board. The recurring themes are contemporaneous documentation, meaningful consent, planned termination, and clear co-management.
Recordkeeping and consent
Create a legible, accurate, contemporaneous record for every encounter: history, examination findings, diagnosis, treatment, advice, prescriptions, referrals, and consent discussion. Do not backdate or alter after a complaint. Retention and release follow Board rule and privacy law; produce copies as authorized and keep the original when required. Informed consent is a process, not a signature. Explain diagnosis, proposed treatment, material risks, alternatives (including no treatment), and likely consequences in terms the patient can use. Contact lens, dilation, pharmaceutical, and co-management decisions each need their own discussion.
Abandonment and referral
Abandonment is unilateral termination without reasonable notice, access to records, and an opportunity to arrange care. A clinician may end a relationship for good cause-nonpayment, repeated no-shows, abusive conduct-but must document the reason, give written notice, offer emergency care for a stated period, and transfer records. Referral and co-management require explicit allocation of responsibility: who checks the pressure, who manages the medication, who handles after-hours problems. Send and document the referral; do not assume the patient arranged it.
Worked example
A patient misses three appointments. The OD sends a letter saying 'you are dismissed' and does nothing else. That is a weak abandonment defense. Better: state the termination date, explain the reason, provide a set period for urgently needed care, offer records to a new provider, and document the mailing.
Traps
Believing a signed form proves informed consent. 'Firing' a patient without notice. Silent co-management where both clinicians assume the other is monitoring.