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.