Reports and prescriptions in the health record

Yes. From March 31, 2026, all healthcare professionals—including freelance ophthalmologists and those working in private clinics—are required to submit ophthalmological reports for services provided to the Electronic Health Record 2.0, as required by Legislative Decree 34/2020 (Relaunch Decree) and subsequent implementing provisions.

The patient and the professionals the law allows to consult it, according to the consents the patient has given. It is not a record shared with anyone: access is regulated and logged.

A minor's health record exists and is managed by whoever holds parental responsibility. On the practice's side the submission does not change: what changes is the consents, which must be collected from whoever is entitled to give them.

Retention is governed by the rules on the health record, not by the software. In the software the documents stay in the patient's record together with the outcomes of the submissions, and they are exported when needed.

The ophthalmologist must submit outpatient reports relating to ophthalmological services provided. This includes the eye examination report with visual acuity, intraocular pressure, ICD-10 diagnosis, instrumental test reports (OCT, visual field, fluorescein angiography, tonometry, biometry, corneal topography), optical prescriptions, and clinical notes. The document must be in HL7 CDA2 format and digitally signed.

Yes. All instrumental tests performed in the clinic must be documented and transmitted to the FSE: OCT (optical coherence tomography), visual field, fluorescein angiography, tonometry, biometry, corneal topography, and other ophthalmological tests. BeebeeDoc integrates automatic reporting of these tests into the CDA2 document.

Optical prescriptions (glasses and contact lens prescriptions) must be included in the ophthalmology report submitted to the FSE as a digitally signed CDA2 document. BeebeeDoc allows you to enter prescriptions directly during the visit and automatically include them in the report.

Ophthalmology ICD-10 codes fall within the H00-H59 range. The most common are: H25 (senile cataracts), H40 (glaucoma), H35.3 (maculopathy), H52 (myopia and astigmatism), H53 (vision disorders), H54 (blindness and low vision), and H43 (vitreous disorders). BeebeeDoc offers an intelligent autocomplete with the most commonly used ICD-10 codes in ophthalmology.