Documentation

Documentation Records must be documented and maintained in accordance with Part 200, Chapter 1, Rule 1.3. The vision medical record documentation must contain the following on each beneficiary: A. Date(s) of service, B. Demographic information, C. Current medical history, D. Examination and/or treatment rendered, E. Specific name/type of all diagnostic studies, and the result/finding of the studies, F. Specific order for all lenses, lens coating, and ocular prosthetics, and G. Provider’s signature.