Part 3, Chapter 9: Manual Exhibit 3-9-F
Primary Eye Care Examination Standards
The basic eye examination, recorded in the Subjective, Objective, Assessment, Plan (SOAP) format, should include:
- A measurement of visual acuity on the first visit and as needed thereafter.
- Chief complaint(s)
- History (or significant history change from last examination), to include at least:
- History of eye injury or disease.
- Significant general health.
- Significant family history.
- Current medications.
- Patient's special visual needs.
- History of medication reactions.
- External examination of the eye and adnexa.
- Evaluation of gross muscle function (motility).
- Pupil responses.
- Best corrected vision (BVA).
- Evaluation of horizontal and vertical muscle balance at distance and near.
- Intraocular pressure. (If in a high risk group.)
- Blood pressure measurements in accordance with Area and IHS protocol.
- The patient's reasons for the visit (chief complaint).
- All significant objective findings.
- Etiology of any visual loss.
- All significant findings.
A treatment plan which includes at least:
NOTE: Significant findings should be recorded on the problem list on the patient's medical record.
- The Treatment.
- All instructions given to the patient (including return interval).
- Referral to other providers for findings of a non-ocular nature.
- Patient education.
- In the-event of other chief complaints or aberrant objective findings, additional specific and/or specialized procedures may be indicated. In these instances the test procedures should follow accepted professional standards or established protocol in accordance with the recommendations of the Area quality assurance standards.
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