Examination Documentaton

After each exam, a copy of the exam form is left at the facility to be kept in the patient’s chart under Progress Notes, Consults, or elsewhere as instructed by the facility. The exam form will contain the following information:

• Date of the exam

• Current glasses prescription and visual acuities

• New glasses prescription, if one is found, along with new visual acuities

• Detailed examination information on cornea, cataracts, retina, and eye pressure

• List of diagnoses and doctor’s recommendations

• The referral box will be checked if the patient is recommended to see an ophthalmologist or a specialist