Section | Required Element |
History | Chief Complaint |
History of Illness |
General Medical Observation |
Examination | Visual Acuity |
Visual Fields (gross or confrontation) |
Extraocular motility |
Intraocular Pressure |
Ocular Adnexa |
Conjunctiva |
Cornea |
Anterior Chamber |
Pupil and Iris |
Lens |
Optic Nerve |
Retina and vessels |
Initiation of Diagnostic and Treatment Program (use one of many possible actions) | Prescription of medication, glasses, contact lenses |
Arranging for diagnostic or treatment services |
Order Consultation |
Order Labs |
Order Radiology testing |
Schedule or perform surgery |
Scheduling necessary follow-up |