|
Time with patient (N: 45=4, 60=5 O:25=4 40=5)
|
|
|
Additional Vision
|
Additional IOP
|
|
VA 1
• • •
|
|
|
OD VA1
|
OS VA1
|
|
VA 2
• • •
|
|
|
OD VA2
|
OS VA2
|
|
OD IOP (additional)
|
OS IOP (additional)
|
|
OPTOMETRY
|
|
|
REFRACTION INFORMATION
|
|
|
OD Entering SRx/CLRx
|
OS Entering SRx/CLRx
|
|
ADD (+)
|
AGE of Rx
|
|
|
|
|
Cover Test at distance
• • •
|
Cover Test at near
• • •
|
|
Keratometry OD
/
|
Keratometry OS
/
|
|
Autorefraction OD
|
Autorefraction OS
|
|
Dry Retinoscopy OD
|
Dry Retinoscopy OS
|
|
|
|
|
Manifest Refraction OD
|
BCVA with Manifest Refraction OD
|
|
|
BCVA -/+ OD
|
|
Manifest Refraction OS
|
BCVA with Manifest Refraction OS
|
|
|
BCVA -/+ OS
|
|
BCVA with Manifest Refraction OU
|
BCVA -/+ OS
|
|
|
|
|
Tentative Near Add OU
|
Near Corrected BCVA OU
/
|
|
|
|
|
Cyclo
|
|
|
Cyclo AR OD/OS
|
Cyclo Retinoscopy OD/OS
|
|
Cyclo Refraction OD
|
BCVA with Manifest Refraction OD
|
|
Cyclo Refraction OS
|
BCVA with Manifest Refraction OS
|
|
|
|
|
Final SRx
|
|
|
Final SRx OD2
|
Final SRx OS
|
|
ADD OU
|
PD
|
|
|
|
|
Final SRx OD
|
Final SRx OS
|
|
ADD (+) final
|
|
|
|
|
|
Externa WNL OU?
|
|
|
OD Externa
|
OS Externa
|
|
|
|
|
EOM WNL OU?
|
|
|
OD EOM
• • •
|
OS EOM
• • •
|
|
OD EOM
|
OS EOM
|
|
|
|
|
Visual Field WNL OU?
|
|
|
OD VF
• • •
|
OS VF
• • •
|
|
OD Visual Field
|
OS Visual Field
|
|
|
|
|
Pupils WNL OU?
|
|
|
OD Pupil
• • •
|
OS Pupil
• • •
|
|
OD Pupil
|
OS Pupil
|
|
|
|
|
Lids WNL OU?
|
|
|
OD Lids
• • •
|
OS Lids
• • •
|
|
OD Lids
|
OS Lids
|
|
|
|
|
Conjunctiva/Sclera WNL OU?
|
|
|
OD Conj/Sclera
• • •
|
OS Conj/Sclera
• • •
|
|
OD Conjunctiva/Sclera:
|
OS Conjunctiva/Sclera:
|
|
|
|
|
Cornea WNL OU?
|
|
|
OD Cornea
• • •
|
OS Cornea
• • •
|
|
OD Cornea
|
OS Cornea
|
|
|
|
|
AC WNL OU?
|
|
|
OD AC
• • •
|
OS AC
• • •
|
|
OD Anterior Chamber
|
OS Anterior Chamber
|
|
|
|
|
Iris WNL OU?
|
|
|
OD Iris
• • •
|
OS Iris
• • •
|
|
OD Iris
|
OS Iris
|
|
|
|
|
Lens WNL OU?
|
|
|
OD Lens
• • •
|
OS Lens
• • •
|
|
OD Lens
|
OS Lens
|
|
|
|
|
Last Gonioscopy
|
|
|
OD Gonio
• • •
|
OS Gonio
• • •
|
|
OD Gonio
|
OS Gonio
|
|
|
|
|
Dilation Drops
|
Dilation today? (needed for NEM4/5 and EEM 5)
|
|
|
|
|
Vitreous WNL OU?
|
|
|
Vitreous OD
• • •
|
Vitreous OS
• • •
|
|
OD Vitreous
|
OS Vitreous
|
|
|
|
|
Disc WNL OU?
|
|
|
Nerve OD
|
OD nerve additional
• • •
|
|
Nerve OS
|
OS nerve additional
• • •
|
|
|
|
|
OD Disc/CDR
|
OS Disc/CDR
|
|
|
|
|
Macula WNL OU?
|
|
|
Macula OD
• • •
|
Macula OS
• • •
|
|
OD Macula
|
OS Macula
|
|
|
|
|
Retina Vessels WNL OU?
|
|
|
Vessels OD
• • •
|
Vessels OS
• • •
|
|
OD Vessels
|
OS Vessels
|
|
|
|
|
Retina Periphery WNL OU?
|
|
|
Periphery OD
• • •
|
Periphery OS
• • •
|
|
OD Periphery
|
OS Periphery
|
|
|
|
|
Other
|
Other
|
|
|
|
|
Exam history
|
|
|
VISUAL FIELD TESTING
|
Date
|
|
Reason
|
Plan
|
|
|
|
|
OD VF Type/Reliability
• • •
|
OD VF Result/Status
• • •
|
|
OD Status
|
Other
|
|
|
|
|
OS VF Type/Reliability
• • •
|
OS VF Result/Status
• • •
|
|
OS Status
|
Other
|
|
|
|
|
OCT NERVE
|
Date
|
|
Reason
• • •
|
Comparison+Plan
• • •
|
|
OD OCT nerve
• • •
|
Thickness
|
|
OS OCT nerve
• • •
|
Thickness
|
|
|
|
|
FUNDUS PHOTOS
|
Date
|
|
Reason
|
Plan
|
|
|
|
|
OD Clarity
• • •
|
OD Photo results
• • •
|
|
OD Status
|
Other
|
|
|
|
|
OS Clarity
• • •
|
OS Photo results
• • •
|
|
OS Status
|
Other
|
|
|
|
|
Last OCT Macula
|
Last OCT RNFL
|
|
Last Fundus Photo
|
Last VF
|
|
Other
|
Other
|
|
Tmax
|
CCT
|
|
Last DFE
|
Primary Care Doctor
|
|
|
|
|
|
|
|
Assessment & Plan
|
|
|
|
|
|
Diabetes type 2
|
Glaucoma
|
|
Dry eyes
|
Cataracts
|
|
Macular degeneration
|
Vitreous Degeneration
|
|
|
|
|
Diabetes Type 2 BOTH eyes
• • •
|
DM2 RIGHT eye
• • •
|
|
|
DM2 LEFT eye
• • •
|
|
|
DM2 Comments
|
|
|
|
|
POAG/GS
• • •
|
CACG
• • •
|
|
|
Glaucoma comments
|
|
|
|
|
DRY EYES
• • •
|
Exacerbations
• • •
|
|
|
DES comments
|
|
|
|
|
CATARACTS
• • •
|
Cataract comments
|
|
|
|
|
MACULAR DEGENERATION OU
• • •
|
Macular degen ONE EYE
• • •
|
|
|
Macular degeneration Comments
|
|
|
|
|
VITREOUS DEGENERATION
• • •
|
Vitreous Degen comments
|
|
|
|
|
Refraction
|
|
|
Refractive Errors BOTH eyes
• • •
|
Refractive Errors RIGHT eyes
• • •
|
|
|
Refractive Errors LEFT eyes
• • •
|
|
|
Refractive Error Comments
|
|
|
|
|
Assessment 1
|
Comments
|
|
|
|
|
Assessment 2
|
Comments
|
|
|
|
|
Assessment 3
|
Comments
|
|
|
|
|
Assessment 4
|
Comments
|
|
|
|
|
Assessment 5
|
Comments
|
|
|
|
|
CPT codes
• • •
|
ICD-10
• • •
|
|
92133 RT
|
92133 LT
|
|
92134 RT
|
92134 LT
|
|
92202 RT
|
92202 LT
|
|
92201 RT
|
92201 LT
|
