Eye Exam

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Eye Examination

 

 

System/Body Area

 

                                                            Elements of Examination

 

Constitutional

 

 

 

Head and Face

 

 

 

Eyes

 

    Test visual acuity (Does not include determination of refractive error)

 

    Gross visual field testing by confrontation

 

    Test ocular motility including primary gaze alignment

 

    Inspection of bulbar and palpebral conjunctivae

 

    Examination of ocular adnexae including lids (eg, ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes

 

    Examination of pupils and irises including  shape, direct and consensual reaction (afferent pupil), size (eg, anisocoria) and morphology

 

    Slit lamp examination of the corneas including  epithelium, stroma, endothelium, and tear film

 

    Slit lamp examination of the anterior chambers including depth, cells, and flare

 

    Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus

 

    Measurement of intraocular pressures (except in children and patients with trauma or infectious disease)

 

Ophthalmoscopic examination through dilated pupils (unless contraindicated) of

 

   Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, tumor elevation) and nerve fiber layer

 

    Posterior segments including retina and vessels (eg, exudates and hemorrhages)

 

Ears, Nose, Mouth and Throat

 

 

 

Neck

 

 

 

Respiratory

 

 

 

Cardiovascular

 

 

 

Chest (Breasts)

 

 

 

Gastrointestinal

(Abdomen)

 

 

 

Genitourinary

 

 

 

Lymphatic

 

 

 

Musculoskeletal

 

 

 

Extremities

 

 

 

Skin

 

 

 

Neurological/

Psychiatric

 

Brief assessment of mental status including

 

·      Orientation to time, place and person

 

·      Mood and affect (eg, depression, anxiety, agitation)

 

 

        Content and Documentation Requirements

 

 

Level of Exam

 

Perform and Document:

 

Problem Focused

 

One to five elements identified by a bullet.

 

Expanded Problem Focused

 

At least six  elements identified by a bullet.

 

Detailed

 

At least nine elements identified by a bullet.

 

Comprehensive

 

Perform all elements identified by a bullet; document every element in each shaded box and at least one element in each unshaded box.