Part 3, Chapter 9: Manual Exhibit 3-9-F
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:
- 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.
NOTE: Significant findings should be recorded on the problem list on the patient's medical record.