Harris M G, Thal L S
University of California, School of Optometry, Berkeley 94720.
J Am Optom Assoc. 1992 Jun;63(6):430-5.
Patient records are essential to provide patients with appropriate health care and to preserve patients' rights. Patient records are also vital to help practitioners defend lawsuits. Therefore, practitioners must maintain patient records in good order for as long as possible. This paper discusses the clinical and legal issues involved in record retention, including the relevant state regulations and record requirements in other health care fields, to provide guidelines for retention of optometric patient records. Based on the statutes of limitations, common practice and sound medical and legal advice, optometric patient records should be retained for a minimum of 10 years after the patient was last seen. Ideally, patient records should be retained forever.
患者记录对于为患者提供适当的医疗保健以及维护患者权利至关重要。患者记录对于帮助从业者辩护诉讼也至关重要。因此，从业者必须尽可能长时间地妥善保管患者记录。本文讨论了记录保存中涉及的临床和法律问题，包括相关的州法规以及其他医疗保健领域的记录要求，以提供验光患者记录保存的指导方针。根据诉讼时效法规、惯例以及合理的医学和法律建议，验光患者记录应在最后一次见到患者后至少保留10年。理想情况下，患者记录应永久保存。
