|
Eye Exam
|
|
|
Neuro Evaluation
|
|
|
Head/Face normal limits?
|
Psych: Mood/Affect
|
|
Neuro: Oriented (person/place/t)
|
|
|
Visual Acuity at Distance
|
Good Reliability
|
|
VA OD cc @ D
|
VA OS cc @ D
|
|
VA OD sc @ D
|
VA OS sc @ D
|
|
VA OU cc @ D
|
VA OU cc @ N
|
|
VA OU sc @ D
|
VA OU sc @ N
|
|
New Short Text Field
|
|
|
Visual Acuity at Near
|
Good Reliability
|
|
VA OD cc @ N
|
VA OS cc @ N
|
|
New Short Text Field
|
|
|
VA OD sc @ N
|
VA OS sc @ N
|
|
Entrance Testing
|
|
|
Pupils PERRLA (-) APD
|
Pupil Comments
|
|
CVF OD
• • •
|
CVF OS
• • •
|
|
EOM
|
EOM Comments
|
|
Cover Test at D
• • •
|
Cover Test at N
• • •
|
|
Color Vision WNL?
|
Color Test
• • •
|
|
Refraction
|
|
|
Habitual Rx OD
|
Habitual Rx OS
|
|
Habitual Add
|
|
|
Autorefraction OD
|
Autorefraction OS
|
|
Retinoscopy OD
|
Retinoscopy OS
|
|
Trial Frame Refraction OD
|
Trial Frame Refraction OS
|
|
Patient appreciates trial frame
|
|
|
Final Rx OD
|
Final Rx OS
|
|
Final Add Power
|
|
|
Final VA OD cc @ D
|
Final VA OS cc @ D
|
|
Final VA OD cc @ N
|
Final VA OS cc @ N
|
|
Anterior Segment
|
|
|
Lids OD WNL
|
Lid/Lacrimal OD
• • •
|
|
|
Lid OD Comments
|
|
Lids OS WNL
|
Lid/Lacrimal OS
• • •
|
|
|
Lid OS Comments
|
|
Conjunctiva/Sclera OD WNL?
|
Conj/Sclera OD
• • •
|
|
|
Conj/Scleara OD Comments
|
|
Conjunctiva/Sclera OS WNL?
|
Conj/Sclera OS
• • •
|
|
|
Conj/Sclera OS Comments
|
|
Tear Film OD WNL
|
Tear Film OD
• • •
|
|
|
Tear Film OD Comments
|
|
Tear Film OS WNL
|
Tear Film OS
• • •
|
|
|
Tear Film OS Comments
|
|
Cornea OD WNL
|
Cornea OD
• • •
|
|
|
Cornea OD Comments
|
|
Cornea OS WNL
|
Cornea OS
• • •
|
|
|
Cornea OS Comments
|
|
Iris WNL OD
|
Iris OD
• • •
|
|
|
Iris OD Comments
|
|
Iris WNL OS
|
Iris OS
• • •
|
|
|
Iris OS Comments
|
|
Ant Chamber OD WNL?
|
Ant Chamber OD
• • •
|
|
|
Ant Chamber OD Comments
|
|
Ant Chamber OS WNL?
|
Ant Chamber OS
• • •
|
|
|
Ant Chamber OS Comments
|
|
Lens OD Clear?
|
Lens OD
• • •
|
|
PCIOL OD?
|
Lens OD Comments
|
|
Lens OS Clear?
|
Lens OS
• • •
|
|
PCIOL OS
|
Lens OS Comments
|
|
IOP
|
|
|
IOP OD
|
Method
|
|
IOP OS
|
Method
|
|
Posterior Segment
|
Poor posterior views secondary to:
• • •
|
|
|
Post Eval Method
• • •
|
|
Dilated
|
Drops used / Comments
• • •
|
|
Macula OD WNL
|
Macula OD
• • •
|
|
|
Macula OD Comments
|
|
Macula OS WNL
|
Macula OS
• • •
|
|
|
Macula OS Comments
|
|
ONH OD
• • •
|
ONH OD Comments
|
|
ONH OS
• • •
|
ONH OS Comments
|
|
Vessels OD WNL
|
Retinal Vessels OD
• • •
|
|
|
Retinal Vessels OD Comments
|
|
Vessels OS WNL
|
Retinal Vessels OS
• • •
|
|
|
Retinal Vessels OS Comments
|
|
Vitreous OD WNL?
|
Vitreous OD
• • •
|
|
|
Vitreous OD Comments
|
|
Vitreous OS WNL?
|
Vitreous OS
• • •
|
|
|
Vitreous OS Comments
|
|
Retina WNL OD
|
Retina OD
• • •
|
|
|
Retina OD Comments
|
|
Retina WNL OS
|
Retina OS
• • •
|
|
|
Retina OS Comments
|
|
Periphery OD WNL?
|
Peripherla Retina OD
• • •
|
|
|
Peripheral Retina OD Comments
|
|
Periphery OS WNL?
|
Peripheral Retina OS
• • •
|
|
|
Peripheral Retina OS Comments
|
