Spotlight on Standard 14 – Record Keeping and Billing

Standard 14 describes how an optician is to maintain accurate, understandable, complete, confidential, and timely client and financial records in accordance with COBC’s bylaws and applicable legislative and regulatory requirements.

To support the application of this standard, COBC has developed additional resources that opticians can use in their work:

Case Study #1

Record keeping for an eyeglasses purchase

Your client is purchasing two pairs of eyeglasses: new progressive lenses in a new frame, and new computer lenses in her old frame. To create the client record, you begin by retrieving your client’s file in the system. You update her information and make a copy of the new prescription to attach to the client file. You note the prescriber and the date of the eye exam. Then, you enter the frame specifications for both the new frame and the client’s own frame. This includes model, colour, and box measurements. You record the lens type, coatings, treatment, PD, seg height, vertex distance, and pantoscopic tilt measurements. You indicate the reasons why the specific lenses were selected based on the client’s lifestyle and work; specifically, you make note of the request for computer lenses and include that the client requires computer lenses for their work. You ensure the client file contains details about the financial transactions and third-party billing. You save the updates to the client file.

Best practices for record keeping related to eyeglasses

Keep the client’s file updated with all frame and lens information, as well as any discussions or recommendations made for future reference. Make it a habit to document your interactions with your clients promptly and in detail, as this will reduce your chances of making an error!

To get another perspective on record keeping, check out this article from the College of Opticians of Ontario.

What criteria from Standard 14: Record Keeping and Billing were considered in the above case study?

14.1 Create and maintain an accurate and truthful client record for each client, including measurements and observations based on the services provided.

14.2 Ensure that all records are updated to reflect new information as it becomes available.

14.3 Comply with all privacy legislation and standards related to the collection of, access to, and disclosure of records.

14.4 Ensure that records are legible and can be understood by the optician, the client, COBC, and other regulated health care professionals.

Case Study #2

Long-term record keeping

You receive a call from an optician in another city. Their new client is experiencing some discomfort in his eyes while wearing his contact lenses and has indicated that the last optician he saw was you. They are requesting that you send the client’s contact lens record over to their store.

Reviewing the client file, you note that you last saw this client just over three years ago for a contact lens fitting. At that time, you sold him a six-month supply of contact lenses.

The optician would like to review your records, including any findings from that last visit. The client has signed a consent form that allows you to release this information, and the optician has provided you with a copy of the signed form.

Best practices for record keeping related to contact lens fitting

Use a contact lens exam/fitting form or software as a guide so that all pertinent information and results are recorded. Document as much information as possible to support your findings.

Why does COBC recommend keeping files for longer than the minimum period of three years?

Section 53(4) of the COBC Bylaws states that opticians must keep records for a minimum of three years from the date of last entry. Meanwhile, the Standards of Practice (14.9) recommend keeping records for seven years from the date of last entry. Some considerations include:

  • Insurance companies’ requirements (applicable with direct billing).
  • Records required by the Canada Revenue Agency.
  • Records that contain co-management information (such as co-management with an ophthalmologist or optometrist).

What additional criteria from Standard 14: Record Keeping and Billing were considered here?

14.5 Maintain client records in a manner that enables timely access, as required, by the client or by an authorized COBC inspector.

14.7 Upon client request, facilitate the timely transfer of the client record to another regulated health care professional, in accordance with relevant legislation.

14.9 Retain all client records for a mandatory minimum of three years and a recommended maximum of seven years from date of last entry.

14.15 Keep clear and legible financial records for all services provided and all vision appliances dispensed, including:
          a. fees for services
          b. product receipts
          c. commercial laboratory work orders
          d. invoices to clients

Review, download, and/or print COBC’s record keeping checklists:

Working on your CCP? Remember that reading and implementing the new Standards of Practice is your professional responsibility—but it can also be used towards your learning goals!

For more information on the standards, please review our new Standards of Practice page on our website.