Performing a Routine Vision Exam

Document pretesting and diagnostic data in the Vision Exam. There are five areas required for billing:

  • Visual acuity
  • Pupils
  • Motility
  • Visual fields
  • IOP

The tabs of the required areas are marked with an asterisk.

This topic describes how

  1. Open the Vision Exam screen.

    For more information, go to Opening the Vision Exam Screen.

    The Vision Exam screen opens and the Wearing (WRx) tab appears.

  2. If needed, make any changes to the fields under Recorded On.

    The fields show today’s date and time.

  3. Select the Eyeglass Type and Eyeglass Options.
  4. On the Refractions tab, click Refraction History and select the refraction you want to import, or enter the details for the patient’s eyeglasses.
    • Refractions. Select the values for the Eyeglass Prescription from the drop-down lists.

      You can click Copy OD to OS to copy the prescription for the right eye to the left eye.

    • Prisms/PD’s. Select the values for the HPrism Base and VPrisim Base.
    • Additional Visual Acuity. Select the patient’s Distance Vision and Near Vision from the drop-down menus.
  5. Enter the Binocular PD.
  6. Select the Eyeglass Usage.
  7. Click Save.
  1. Open the Vision Exam screen.

    For more information, go to Opening the Vision Exam Screen.

  2. Click Auto Refraction.

    If you have an autorefractor integrated with Eyefinity EHR, click the Equipment Interface button on the action bar to open a list of your equipment. Select the instrument you're using from the list, run the autorefractor, and print from the device to pull in the results.

  3. If needed, make any changes to the fields under Recorded On.

    The fields show today’s date and time.

  4. On the Refractions tab, click Refraction History and select the refraction you want to import, or enter the details for the patient’s refraction.
    • Refractions. Select the values for the refraction from the drop-down lists.

      You can click Copy OD to OS to copy the prescription for the right eye to the left eye.

    • Prisms/PD’s. Select the values for the HPrism Base and VPrisim Base.
    • Additional Visual Acuity. Select the patient’s Distance Vision and Near Vision from the drop-down menus.
  5. Enter the Binocular PD.
  6. Enter the Reading Distance.
  7. Click Save.
  1. Open the Vision Exam screen.

    For more information, go to Opening the Vision Exam Screen.

  2. Click Visual Acuity (Va)*.
  3. Select the Distance Test Type and Near Test Type.
  4. If needed, make any changes to the fields under Recorded On.

    The fields show today’s date and time.

  5. For Corrected Vision:
    1. Select the Distance Correction Type and the Distance Visual Acuity.
    2. Select the Near Correction Type and the Near Visual Acuity.
  6. For Uncorrected Vision:
    1. Select the Distance Correction Type and the Distance Visual Acuity.
    2. Select the Near Correction Type and the Near Visual Acuity.
  7. Click Save.
  1. Open the Vision Exam screen.

    For more information, go to Opening the Vision Exam Screen.

  2. Click Refractions.

  3. Select the type of refraction you want to add from the drop-down list or click Create Final Rx.

    For more information on creating a final Rx, see To create the final prescription for glasses.

  4. Click Refraction History and select the refraction you want to import, or enter the details for the patient’s refraction.
    • Refractions. Select the values for the refraction from the drop-down lists.

      You can click Copy OD to OS to copy the prescription for the right eye to the left eye.

    • Prisms/PD’s. Select the values for the HPrism Base and VPrisim Base.
    • Additional Visual Acuity. Select the patient’s Distance Vision and Near Vision from the drop-down menus.
  5. Select the Eyeglass Usage.
  6. Enter the Binocular PD.
  7. Enter the Reading Distance.
  8. Click Save.
  1. Open the Vision Exam screen.

    For more information, go to Opening the Vision Exam Screen.

  2. Click Refractions.

  3. Under Create/Update Measurement Set, click Create Final Rx.

    If you already have a Saved Measurement Set you want to make final, you can click Create Final Rx on it to instantly create a final Rx.

  4. Enter the details for the patient’s refraction.
    • Refractions. Select the values for the refraction from the drop-down menus.

      You can click Copy OD to OS to copy the prescription for the right eye to the left eye.

    • Prisms/PD’s. Select the values for the HPrism Base and VPrisim Base.
    • Additional Visual Acuity. Select the patient’s Distance Vision and Near Vision from the drop-down menus.
  5. Select the Eyeglass Usage.
  6. Enter the Binocular PD.
  7. Enter the Reading Distance.
  8. Click Save.
  1. Open the Vision Exam screen.

    For more information, go to Opening the Vision Exam Screen.

  2. Click Pupils*.
  3. Click Mark as Normal, or document the specific results.
  4. Click Save.
  1. Open the Vision Exam screen.

    For more information, go to Opening the Vision Exam Screen.

  2. Click Motility*.
  3. Click Mark as Normal or select the test type from the drop-down list. The options are:
    • Ductions and Versions. Select the values for the right and left eye on the drawing.
    • Cover-Uncover. Select the Near and Distance values.
    • Alternate Cover. Select the Top, Middle and Bottom values.
    • Reflex. Select the Hirschberg and Krimsky values.
  4. Click Save.
  1. Open the Vision Exam screen.

    For more information, go to Opening the Vision Exam Screen.

  2. Click Visual Fields*.
  3. Click Mark as Normal, or select the test type and test results. Mark any problem areas on the Visual Field diagram.
  4. Click Save.
  1. Open the Vision Exam screen.

    For more information, go to Opening the Vision Exam Screen.

  2. Click IOP*.
  3. Enter the IOP readings.
  4. Click Save.
  1. Open the Vision Exam screen.

    For more information, go to Opening the Vision Exam Screen.

  2. Click Diagnostic Drops.
  3. Select the dilation solution used for the right eye.
  4. Select the dilation solution used for the left eye.
  5. Under Counsel, indicate whether you have counseled the patient.
  6. Click Save.

Want to watch a video tutorial on documenting the vision exam? Check out our series on Pretesting and Creating Prescriptions (Browser).