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Interpreter Refused
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Chief Complaint-reason for visit
• • •
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Chief Complaint Comments
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FOLDARS
• • •
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MHx/FHx/Meds/Allergies REVIEWED
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NEUROLOGIC
• • •
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Unaided VA 20/20?
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Blood Pressure
/
|
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Unaided VA NOT 20/20?
|
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VAsc @ Distance OD
• • •
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VAsc @ Distance OS
• • •
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VAsc @ Distance OU
• • •
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VAsc @ Near OD
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VAsc @ Near OS
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PD:
|
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Contact Lens History?
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Entering CL Rx OD
|
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Entering CL Rx OS
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CL History Comments
|
|
|
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Presenting Glasses?
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Entering Spectacle RX OD
|
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Entering Spectacle Rx OS
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ADD (+)
|
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Aided VAs 20/20?
|
|
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AIDED VA NOT 20/20?
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VAcc @ Distance OD
• • •
|
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ENTRANCE TEST
|
VAcc @ Distance OS
• • •
|
|
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VAcc @ Near OU
• • •
|
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Entrance Testing All Normal
|
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Show ALL entrance test?
|
IOP OD
|
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IOP OS
|
Entrance Testing All Normal
• • •
|
|
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STEREOVISION
• • •
|
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COLOR VISION (Ishihara): OD
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COLOR VISION (Ishihara): OS
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PUPILS
• • •
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COVER TEST
• • •
|
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EOM
• • •
|
Cover Test Comments
|
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NPC
|
CVF
• • •
|
|
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Confrontation VF Comments
|
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SUBJECTIVE
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AUTOKERATOMETRY OD / OS
|
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Autorefraction OD
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Autorefraction OS
|
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SUBJECTIVE REFRACTION OD
|
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SUBJECTIVE REFRACTION OS
|
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ADD (+)
|
|
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BCVA all 20/20?
|
|
|
Aided VA NOT 20/20?
|
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BCVA Distance OD
• • •
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BCVA Distance OS
• • •
|
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BCVA Near OD
|
BCVA Near VA OS
|
|
|
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Binocular Testing?
|
Trial Frame
|
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PHORIA DIST
|
|
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WET/CYCLO
|
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NRA(+)/PRA(-)
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PHORIA NEAR
|
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MODIFIED RX OD
|
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MODIFIED RX OS
|
|
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MODIFIED ADD
|
CYCLO VA
|
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OBJECTIVE
|
|
|
ANT SEG ALL Normal OU
|
|
|
Show ALL Anterior Segment
|
|
|
ANT SEG NORMAL OU
• • •
|
Anterior Segment Comments
|
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OCULAR ADNEXA
• • •
|
OA Comments:
|
|
EYELIDS/LASHES
• • •
|
Lids/Lashes Comments
|
|
SCLERA/EPISCLERA
• • •
|
S/E Comments
|
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CONJUNCTIVA
• • •
|
Conj Comments
|
|
CORNEA
• • •
|
Cornea Comments
|
|
IRIS
• • •
|
Iris Comments
|
|
ANTERIOR CHAMBER
• • •
|
AC Comments
|
|
Lacrimal OD
|
Lacrimal OS
|
|
Anterior Segment OD
|
Anterior Segment OS
|
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GAT?
|
|
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Tonometry Method OU
|
IOP OD/OS
/
|
|
ANGLE ESTIMATE
• • •
|
|
|
DILATION
|
|
|
Post Seg All Normal
|
|
|
Show ALL Posterior Segment?
|
Dilation Refusal SIG
|
|
Post Segment All Normal
• • •
|
Posterior Segment Comments
|
|
LENS
• • •
|
Lens commments
|
|
MACULA
• • •
|
Macula Comments:
|
|
FOVEAL REFLEX OU?
|
|
|
VITREOUS
• • •
|
Vitreous Comments
|
|
VASCULATURE
• • •
|
Vasculature Comments
|
|
POSTERIOR POLE
• • •
|
Post Pole Comments
|
|
PERIPHERY
• • •
|
Periphery Comments
|
|
OPTIC NERVE
• • •
|
ONH Comments
|
|
|
ONH Comments
|
|
Cup to Disc Ratio OD
• • •
|
|
|
Cup to Disc Ratio OS
• • •
|
|
|
|
|
|
No diabetic retinopathy?
|
Retinopathy Comments
|
|
Visual Field
|
|
|
Interpretation OD
• • •
|
Reliability OD
• • •
|
|
Interpretation OS
• • •
|
Reliability OS
• • •
|
|
DOCUMENTS
|
|
|
Retina OD
|
Retina OS
|
|
Pretesting Documents
|
VF Documents
|
|
Patient History Form
|
Miscellaneous Forms (DMV, Referrals)
|
|
Patient Exam Form
|
|
|
CONTACT LENS
|
|
|
Contact Lens Exam
|
|
|
Contact Lens OD
• • •
|
Power
|
|
Contact Lens OS
• • •
|
Power
|
|
Over Refraction OD
|
Over Refraction OS
|
|
CL VA all 20/20?
|
|
|
BCVA with CL OD
|
BCVA with CL OS
|
|
CL fit All Normal
|
|
|
CL Fit Evaluation / Comments OD
• • •
|
CL Fit Evaluation / Comments OS
• • •
|
|
Contact trial #2?
|
CL TRIAL #2
|
|
Contact Lens OD
• • •
|
Power
|
|
Contact Lens OS
• • •
|
Power
|
|
CL VA all 20/20?
|
|
|
BCVA with CL OD
|
BCVA with CL OS
|
|
Contact trial #3?
|
|
|
Contact Lens OD
• • •
|
Power
|
|
Contact Lens OS
• • •
|
Power
|
|
CL VA all 20/20?
|
|
|
BCVA with CL OD
|
BCVA with CL OS
|
|
Order CL trials?
|
|
|
Contact Lens OD
• • •
|
Power
|
|
Contact Lens OS
• • •
|
Power
|
|
Additional trials to be ordered
|
|
|
CL Dispensed?
|
|
|
Which trials dispensed?
• • •
|
|
|
Replacement Frequency
|
|
|
CL Solution
• • •
|
Status
• • •
|
|
ASSESSMENT/PLAN
|
|
|
Assessment
• • •
|
Comments
|
|
Assessment
• • •
|
Comments
|
|
Assessment
• • •
|
Comments
|
|
Assessment
• • •
|
Comments
|
|
PLAN
|
|
|
Plan
• • •
|
Comments
|
|
Plan
• • •
|
Comments
|
|
Plan
• • •
|
Comments
|
|
Plan
• • •
|
Comments
|
|
Electronic Signature
|
|
|
|
Comments
|
