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Chief Complaint
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No problems
|
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CC
• • •
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Additional CC
• • •
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Chief Complaint General Notes
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LEE
|
LEE Additional Notes
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LDFE
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LDFE Additional Notes
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Additional glasses?
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Additional Glasses 1
• • •
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OD Sign
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OD Sph
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OD Cyl
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OD Axis
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OS Sign
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OS Sph
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OS Cyl
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OS Axis
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ADD OD
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ADD OS
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Additional Notes
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Acuity With Correction
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VA CC
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VA CC is 20/20
|
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VA CC OD
|
OD additional acuity
• • •
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VA CC OS
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OS additional acuity
• • •
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Comments on VA
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VA CL
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VA CL OD
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VA CL OS
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VA CL OU
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Acuity Without Correction
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VA SC
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VA SC OD
|
OD additional acuity
• • •
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VA SC OS
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OS additional acuity
• • •
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VA SC OU
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Comments on VA
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Chair Tests
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Chair Tests
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Pupils
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Additional notes
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EOMS
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EOMS Additional Notes
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CVF
|
CT distance
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CT near
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Color Vision
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Additional Notes
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Additional Entrance Testing
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NPC
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NRA/PRA
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Stereopsis
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Additional Testing
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Autorefraction/
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Autorefraction
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OD Sign
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OD Sph
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OD Cyl
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OD Axis
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OS Sign
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OS Sph
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OS Cyl
|
OS Axis
|
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Retinoscopy
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OD
|
OS
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Retinoscopy Type
|
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Manifest Refraction
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Manifest Rx OD
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(manifest) OD Sign
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OD Sph (manifest)
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OD Cyl (manifest)
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OD Axis (manifest)
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DVA CC OD (manifest)
• • •
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ADD OD (manifest)
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Manifest Rx OS
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OS Sign (manifest)
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OS Sph (manifest)
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(manifest) OS Cyl
|
OS Axis (manifest)
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DVA CC OS
• • •
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ADD OS (manifest)
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Additional Notes
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Contact Lenses
|
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Contact Lens Evaluation?
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Habitual Contact Lens?
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Vistakon
|
Brand
|
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Alcon
|
Brand
|
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Cooper
|
Brand
|
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B&L
|
Brand
|
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SCOUT by WP
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Other / Comments
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Lids / Tear Film
|
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CL Trial #1
|
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OD Trial 1 Brand
|
CL Trial Rx OD
|
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OS Trial 1 Brand
|
CL Trial Rx OS
|
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Movement
|
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Centration
|
Rotation
|
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New Single Select
|
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Needs Over Refract
|
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Over Refraction OD
|
Over Refraction VA
|
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Over Refraction OS
|
Over Refraction VA
|
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Comments on CL fit/eval
|
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Obligatory Info about CL wear/warnings
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Acuities/AR/K's/Refraction
|
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AR / Ks / Manifest Output from instrument
|
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Trial Frame
|
|
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Trial Frame OD
|
Trial Frame OS
|
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Trial Frame Additional Comments
|
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Additional Final Glasses?
|
|
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#1 Type
• • •
|
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#1 OD
|
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#1 OS
|
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#1 ADD
|
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#2 Type
• • •
|
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#2 OD
|
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#2 OS
|
|
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#2 ADD
|
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ANTERIOR SEG
|
Anterior Seg
|
|
LLL
• • •
|
LIDS OTHER
|
|
PALP CONJ
• • •
|
CONJ OTHER
|
|
BULB CONJ
• • •
|
CONJ OTHER
|
|
CORNEA
• • •
|
CORNEA OTHER
|
|
IRIS
• • •
|
IRIS OTHER
|
|
A/C
• • •
|
A/C OTHER
|
|
ANGLES
• • •
|
ANGLES OTHER
|
|
LENS
• • •
|
LENS OTHER
|
|
TEAR QUALITY
• • •
|
TEAR FILM OTHER
|
|
Anterior Seg
|
Additional images
|
|
Additional images
|
|
|
TONOMETRY
|
Tonometry
|
|
Type
|
Drops
• • •
|
|
OD mmHg
|
OS mmHg
|
|
New Multiple Select
• • •
|
tono comments
|
|
POSTERIOR SEG
|
Posterior Seg
|
|
DFE / Optomap / Declined?
• • •
|
New Short Text Field
|
|
Time
|
|
|
Patient is minor?
|
|
|
Parent or guardian present with child
|
|
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Optic Nerve OD
• • •
|
OPTIC DISC OD
|
|
Optic Nerve OS
• • •
|
OPTIC DISC OS
|
|
OD C/D ratio Vertical (or round)
|
OD C/D Horizontal
|
|
OS C/D ratio Vertical (or round)
|
OS C/D Horizontal
|
|
Macula OD
• • •
|
MACULA OD
|
|
Macula OS
• • •
|
MACULA OS
|
|
VESSELS OD
|
VESSELS OS
|
|
VITREOUS
• • •
|
VITREOUS OTHER
|
|
PERIPHERAL RETINA OD
• • •
|
PERIPHERAL RETINA OD comments
|
|
PERIPHERY OS
• • •
|
PERIPHERAL RETINA OS comments
|
|
other post seg notes
|
DFE Diagram
|
|
Additional images
|
Additional images
|
|
|
|
|
Assessment
• • •
|
notes
|
|
Higher risk of RD?
|
|
|
Plan
• • •
|
Notes
|
|
Needs F/u
|
|
|
RTC Acuity Recheck
|
OHTN
|
|
Needs DFE
|
Nevus check
|
|
Chart Review
|
New Short Text Field
|
|
New Free Draw
|
|
|
Referral UNderstanding
• • •
|
|
|
New Short Text Field
|
|
|
Referral Acknowledgment
|
|
|
Insurance
|
|
