> ## Documentation Index
> Fetch the complete documentation index at: https://docs.bizaxl.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Eye Examination
> How to record a complete eye examination - visual acuity, refraction, slit lamp findings, fundus assessment, diagnosis, prescription, and investigation orders - in a single examination record.
The eye examination record (called a Patient Encounter) is the central document in your eye care system. It is where the doctor or optometrist records everything that happened during a patient visit: what the patient complained about, what was found on examination, the diagnosis, the optical prescription, any medications prescribed, and any investigations or procedures ordered.
Everything else in the system - prescriptions, investigation orders, referrals, and billing - traces back to this examination record.
***
## Before You Start
* The patient must be registered.
* An appointment should exist for this visit.
* You need the **Healthcare Practitioner** role (Ophthalmologist or Optometrist).
* Pre-screening vital signs and visual acuity should already be recorded by the ophthalmic technician before you start.
***
## Starting an Examination
The quickest way is from the appointment:
1. Open the patient's **Patient Appointment** record
2. Click **Create Patient Encounter**
Alternatively:
1. Go to Healthcare workspace → Consultation card → **Patient Encounter** → New
The patient, practitioner, and date auto-fill.
***
## Recording the Chief Complaint
In the **Symptoms** section, add what the patient has come in for:
Common eye care complaints to add:
* Blurry vision (distance or near)
* Eye pain or discomfort
* Redness
* Floaters or flashes of light
* Dry eyes
* Watery eyes / discharge
* Headaches after reading
* Sudden vision loss
* Double vision
* Halos around lights
Select from your configured Complaint master or type a new entry. Add as many as apply.
***
## Recording Examination Findings
Use the **Review Details** (free text) field to record clinical findings that do not fit into structured fields:
For an eye examination, this typically includes:
```
VA Distance (Unaided): RE: 6/36 LE: 6/24
VA Distance (Corrected): RE: 6/6 LE: 6/6
Refraction:
RE: -2.00/-0.50x180 Add: +2.00
LE: -1.75/-0.75x170 Add: +2.00
PD: 64mm
Cover Test: Orthophoric
Ocular Motility: Full and free
Pupils: Equal, round, reactive to light. No RAPD.
Slit Lamp:
Lids/Lashes: Normal
Conjunctiva: Clear, no injection
Cornea: Clear
Anterior Chamber: Deep and quiet
Iris: Normal
Lens: Nuclear sclerosis grade 1 RE, clear LE
IOP: RE: 14mmHg LE: 16mmHg (Goldmann AT)
Fundus:
Disc: Cup:Disc ratio 0.4 RE, 0.4 LE. Normal rim. No pallor.
Macula: Flat and healthy. Foveal reflex present.
Periphery: No breaks or detachment.
```
***
## Recording the Diagnosis
In the **Diagnosis** section:
1. Click in the Diagnosis field
2. Type the diagnosis and select from the configured list
Common eye care diagnoses to configure:
* Myopia (Shortsightedness)
* Hypermetropia (Longsightedness)
* Astigmatism
* Presbyopia
* Dry Eye Disease
* Glaucoma (Open-Angle, Angle-Closure, Normal Tension)
* Glaucoma Suspect
* Cataract (Nuclear, Cortical, Posterior Subcapsular)
* Age-Related Macular Degeneration (Dry AMD, Wet AMD)
* Diabetic Retinopathy (NPDR - Mild, Moderate, Severe; PDR)
* Retinal Detachment
* Hypertensive Retinopathy
* Blepharitis
* Conjunctivitis (Allergic, Bacterial, Viral)
* Keratoconus
* Amblyopia
* Strabismus
Multiple diagnoses can be added in the same examination.
***
## Recording the Optical Prescription
The drug prescription section is used to record the spectacle prescription as well as any eye drop medications.
### Spectacle Prescription
Add the spectacle prescription as a line in the **Drug Prescription** section:
1. In the Drug Code field, enter the prescription as a structured medication entry
2. In the Dosage/Notes field, record the full prescription values:
```
RIGHT EYE: Sphere -2.00 / Cyl -0.50 / Axis 180 / Add +2.00
LEFT EYE: Sphere -1.75 / Cyl -0.75 / Axis 170 / Add +2.00
PD: 64mm
```
Alternatively, use the **Review Details** free text field (above) to record the refraction and prescription, and use the Drug Prescription section only for medications.
### Eye Drop and Medication Prescription
For prescribed eye drops and systemic medications:
| Field | What to Enter |
| ---------------- | ------------------------------------------------------------------------------ |
| Drug Code | The medication name (e.g., Timolol 0.5%, Latanoprost 0.005%, Artificial Tears) |
| Dosage Form | Eye drops, tablet, ointment, injection |
| Strength | Concentration |
| Dosage | How many drops or tablets per dose |
| Period | Duration (lifelong for glaucoma drops, or a specific period) |
| Dosage Frequency | When to use (once daily at night, twice daily, four times daily, etc.) |
For glaucoma drops, note the eye (right, left, or both) in the dosage instructions.
***
## Ordering Investigations
In the **Clinical Procedures** section, order any investigations needed:
Common eye care investigations to configure as Clinical Procedure Templates:
| Investigation | When Ordered |
| ------------------------------ | --------------------------------------------------------------- |
| Non-Contact Tonometry (NCT) | Routine IOP check |
| Goldmann Applanation Tonometry | Accurate IOP measurement for glaucoma patients |
| OCT - Macula | Macular conditions (AMD, diabetic maculopathy, ERM) |
| OCT - Disc/RNFL | Glaucoma monitoring and diagnosis |
| OCT - Anterior Segment | Corneal conditions, angle assessment |
| Visual Field Test (Perimetry) | Glaucoma monitoring, neurological cases |
| Fundus Photography | Diabetic screening, retinal documentation |
| Fluorescein Angiography (FFA) | Wet AMD, retinal vascular disease |
| Corneal Topography | Keratoconus, pre-LASIK, corneal irregularity |
| Pachymetry | Glaucoma (corneal thickness affects IOP), pre-LASIK |
| Biometry | Cataract surgical planning (IOL power calculation) |
| Color Vision Test (Ishihara) | Congenital color vision defects, optic nerve assessment |
| Specular Microscopy | Corneal endothelial cell count (pre/post surgery) |
| B-Scan Ultrasound | When fundus view is poor (dense cataract, vitreous haemorrhage) |
| Gonioscopy | Angle assessment for glaucoma |
Select the investigation template and it will appear in the patient's investigation queue for the technician to complete.
***
## Ordering Lab Tests
For pre-operative patients or patients with systemic disease:
In the **Lab Tests** section, add the required tests:
* Blood Sugar (fasting and/or random) - for diabetic patients and pre-operative assessment
* HbA1c - for diabetic retinopathy patients
* Complete Blood Count (CBC) - pre-operative
* Urine Routine - pre-operative
* Conjunctival swab culture - for infective conjunctivitis or pre-operative infection screening
* ECG - for older surgical patients
***
## Applying a Treatment Plan Template
For common eye conditions, you can set up treatment plan templates that pre-fill standard orders:
1. Click **Get Applicable Treatment Plans** at the top of the form
2. Select the template (e.g., "Glaucoma Management - New Diagnosis" or "Diabetic Retinopathy Monitoring Protocol")
3. All standard investigations and medications fill in automatically
4. Review and adjust for this specific patient
***
## Submitting the Examination
When the examination is complete:
1. Review all entries - complaints, findings, diagnosis, prescriptions, investigation orders
2. Click **Save** (auto-creates investigation and lab test records if enabled)
3. Click **Submit** to finalise
Once submitted, the appointment closes and the examination is locked. Use **Amend** if a correction is needed after submission.
***
## Field Guide: Patient Encounter (Eye Examination)
| Field | What It Contains |
| ----------------------- | -------------------------------------------------------------- |
| Patient | The patient being examined |
| Healthcare Practitioner | The examining doctor or optometrist |
| Encounter Date | Date of the examination |
| Appointment | Linked appointment (auto-filled) |
| Status | Draft or Submitted |
| Symptoms | Chief complaint(s) |
| Diagnosis | Diagnosis codes |
| Drug Prescription | Spectacle prescription, eye drops, systemic medications |
| Lab Tests | Pre-operative and other blood/culture tests ordered |
| Clinical Procedures | Investigations ordered (OCT, Visual Fields, Photography, etc.) |
| Review Details | Free text: VA, refraction, slit lamp findings, IOP, fundus |
| Invoiced | Whether the consultation fee has been billed |
***
## Troubleshooting
**Investigation records were not created when I submitted the examination**
Check that "Submit Orders on Save" is ticked in the encounter, and that it is enabled in Healthcare Settings. If not, create the Clinical Procedure records manually.
**I cannot edit a submitted examination**
Submitted records are locked. Use Amend to create a corrected version.
**The patient's prescription is not on the portal**
Prescriptions appear in the portal only after the encounter is submitted. Check that the patient's portal account is active.
***
## Best Practices
* Always note the visual acuity in the Review Details field even if pre-screening recorded it - the doctor's final VA measurement is the clinically significant one
* For glaucoma patients, always record the IOP measurement method (Goldmann, NCT, iCare) alongside the value - different instruments give different readings
* When ordering investigations, note in the clinical notes why each investigation was ordered - this helps the technician prioritise and helps future clinicians interpret the results in context
* Never leave the Diagnosis field blank - an examination without a diagnosis cannot generate diagnosis trend data and may cause billing issues
* For cataract patients, note the grade of cataract (nuclear sclerosis grade 1-4, cortical, PSC) and whether it is affecting the patient's visual function - this is needed when deciding the right time for surgery
***
## Related Features
* [Appointments](/health-wellness/eye-care-center/appointments): The appointment that starts the examination
* [Optical Prescription](/health-wellness/eye-care-center/optical-prescription): Spectacle and contact lens prescriptions in detail
* [Clinical Investigations](/health-wellness/eye-care-center/clinical-investigations): OCT, visual fields, and other investigation records
* [Surgical Procedures](/health-wellness/eye-care-center/surgical-procedures): Surgical orders from the examination
* [Billing and Finance](/health-wellness/eye-care-center/billing-finance): The examination generates the primary billing event