The physical examination elements of an eye examination are ten (10) in number and include:

1. confrontation visual fields
2. eyelids and adnexa
3. ocular motility
4. pupils/iris
5. cornea
6. anterior chamber
7. lens
8. IOP
9. retina (vitreous, macula, periphery, and vessels)
10. optic disc

Comprehensive exam: 8 or more elements, and always a fundus exam, the pupils dilated if a cycloplegic exam is also included

 Medical record documentation

Medical record review

Established patient: a patient that has received services within the past three years

 A comprehensive history requires a: (1. CC; 2. extended HPI; 3. complete ROS; 4. complete PFSH)

I. HISTORY

A. CHIEF COMPLAINT

The medical record should clearly reflect the chief complaint

1. symptoms
2. problem
3. condition
4. diagnosis
5. and/or other factors that are the reason for the examination
   • doctor recommended return

    

B. HISTORY OF PRESENT ILLNESS

Brief} 1-3 elements

Extended { 4 elements }

1. signs and symptoms
2. location
3. quality
4. severity
5. timing
6. context
7. modifying factors
8. associated signs and symptoms

C. REVIEW OF SYSTEMS

brief {1-4 systems}

Complete {9 systems}

1. constitutional
   • temperature
   • weight
   • height
   • general appearance
   • communication ability
2. ear, nose, throat
3. cardiovascular
4. respiratory
5. gastrointestinal
6. genitourinary
7. musculoskeletal
8. integumentary
9. neurologic
10. psychiatric
11. endocrine
12. hematologic/lymphatic
13. allergy/immunological

D. PAST, FAMILY SOCIAL HISTORY

Brief {1 item from 1-2 areas}

Complete: established patient {1 item from 2 of 3 areas} new patient {1 item from 3 of 3 areas}

A. Past History

1. review of major illnesses
2. hospitalizations
3. surgeries
4. injuries/trauma
5. developmental history

B. Family History

1. health status of children, family
2. hereditary diseases
3. cancer
4. cardiovascular disease
5. domestic violence

C. Social History

1. marital status
2. employment
3. occupation
4. educational level
5. use of alcohol, tobacco
6. exercise patterns

D. Neurological / Psychiatric (brief assessment of mental status)

1. orientation to time, place or person

2. mood / affect

depression

anxiety

agitation

E. REVIEW OF OCULAR SYSTEM

EXAMINATION {12 items}

STRUCTURE	OBSERVATION
inspection of bulbar & palpebral conjunctiva	redness, lesions
visual acuity (not including refractive error)
gross visual field testing by confrontation	hemianopsia
ocular motility including primary gaze alignment	versions, strabismus, nystagmus
examination of adnexa (lids, lacrimal lacrimal drainage)	ptosis, epiphora, lid lag
slit lamp exam of the cornea	epithelium, stroma, endothelium, tear film, dystrophies
slit lamp exam of the lens	opacification, clarity, lens cortex, nucleus
slit lamp exam of the anterior chamber	depth, cells, flare
examination of pupil and iris	shape, direct, consensual reaction, size
measurement of IOP
ophthalmoscopic exam of optic disc (with dilation)	C/D ratio, appearance, hemorrhages, exudates
ophthalmoscopic exam of the posterior segment, retina, vessels (with dilation)	lattice degeneration, holes, tears, detachments, A-V ratio

Medical record documentation

Medical record review