Optometry Contact Lens Evaluation Note (New Fit/Refit)

Header Fields

Date of Service: [date]

Provider: [name and credentials]

Location: [practice location]

Encounter Type: [New Fit / Refit]

Lens Category: [Soft spherical / soft toric / multifocal / GP corneal / scleral / ortho-k / other specialty] (List all that apply)

Related Comprehensive Exam Date: [date] [dilated / undilated / not applicable] (Include if performed separately)

Subjective

[Chief complaint and contact lens goals] (Brief narrative describing patient's goals and primary concerns. Include one concise direct patient quote if it clarifies intent. For new wearers, state primary motivation. For refits, state the reason for change.)

Contact Lens Wearing History

• [Prior or current lens brand/design, BC, DIA, power (sphere/cyl x axis, add if applicable)] (If unknown, document as "Unknown" and note impact on refit planning)
• [Replacement schedule and modality] (e.g., daily disposable, 2-week, monthly)
• [Average daily wear time and days per week]
• [Comfort pattern] (on insertion vs end of day; include only if stated)
• [Vision complaints] (blur, fluctuations, glare/halos; include only if stated)
• [Lens care system and brand] (multipurpose vs peroxide; include brand if stated)
• [Case replacement habits] (include only if stated)
• [Sleep in lenses / water exposure] (document behaviors if present)
• [Prior complications] (infiltrates, GPC, overwear, keratitis; include only if stated)
• (For new wearers, document "No prior contact lens wear" and note any handling concerns or readiness factors)

Relevant Ocular History

• [Dry eye symptoms / allergies or atopy / blepharitis-MGD / recurrent erosions / HSV history / corneal dystrophies / prior ocular surgery or trauma / keratoconus-ectasia / prior refractive surgery] (Include only conditions explicitly mentioned)

Relevant Medical History and Medications

• [Systemic conditions] (e.g., autoimmune disease, diabetes, immunosuppression; include only if stated)
• [Systemic medications affecting tear film] (e.g., antihistamines, isotretinoin, antidepressants; include only if stated)
• [Current topical ocular medications] (include dosing if provided)

Allergies

• [Medication allergies] (include reactions if stated)
• [Solution or preservative sensitivities] (document brand/agent if known)

Objective

(Format OD/OS. When values are imported or carried forward, note the source and date. If a measurement was not performed, document "Not performed" with brief reason.)

Visual Acuity and Refraction

• Habitual Correction: [glasses / contacts / none]
• Unaided VA: OD: [distance VA; near VA if relevant] / OS: [distance VA; near VA if relevant]
• Habitual VA: OD: [VA] / OS: [VA] (Include only if different from unaided)
• Manifest Refraction: OD: [sphere, cyl x axis] [BCVA] / OS: [sphere, cyl x axis] [BCVA] (If performed at separate visit, reference date)

Keratometry / Corneal Measurements

• K Readings: OD: [flat K @ axis / steep K @ axis] / OS: [flat K @ axis / steep K @ axis]
• HVID: OD: [mm] / OS: [mm] (Include if used for diameter selection)
• [Corneal irregularity notes] (asymmetry, inferior steepening, ectasia signs; include topography/tomography summary or sagittal height metrics for specialty fits if performed)

Tear Film and Lid Evaluation

• [TBUT or NIBUT]
• [Tear meniscus assessment]
• [Lid margin and meibomian gland function]
• [Presence/absence of papillae]
• [Corneal/conjunctival/lid margin staining] (include grading scale and location if used)
• [Dry eye screening score] (e.g., OSDI-6 with score; include if performed)

Slit Lamp Examination (Pre-Lens)

• [Lids/lashes]
• [Conjunctiva] (bulbar/palpebral; injection, papillae, follicles)
• [Cornea] (clarity, scars, staining, neovascularization, infiltrates)
• [Limbus] (vascularization, integrity)
• (Include clinically meaningful negatives when specifically assessed, e.g., "No corneal staining," "No neovascularization")

Contraindications or Caution Flags

• [Active infection/inflammation / significant epithelial compromise / uncontrolled dry eye / handling limitations / high-risk behaviors] (Include only if present; describe impact on fitting approach)

Contact Lens Evaluation

Lens Selection Rationale

[Brief rationale] (Explain lens type, material, and modality choices based on refractive needs, corneal geometry, ocular surface status, lifestyle goals, and prior tolerance. If extended wear, overnight ortho-k, or myopia management are prescribed, document indication and that risk counseling was provided.)

Trial Lens and Fit Assessment

(Structure by eye. Include only applicable lens-type-specific subsections.)

• OD Trial: [Brand/design, BC, DIA, Power, Cyl/Axis, Add]

  Settling Time: [minutes]

  Fit Assessment: [centration] / [corneal coverage] / [movement on blink] / [push-up response] (Note edge lift, impingement, conjunctival drag, or tight/loose fit indicators if present)

  Toric-specific: [rotation (degrees and direction)] / [stability after blink] / [axis compensation method if applied]

  Multifocal-specific: [distance/near subjective quality] / [halos/glare] / [dominance strategy if modified monovision]

  GP-specific: [comfort rating] / [movement on blink] / [fluorescein pattern: central, mid-peripheral, edge with timing] / [lid attachment vs interpalpebral position]

  Scleral-specific: [filling solution] / [central vault/clearance with method] / [limbal clearance] / [landing zone alignment] / [bubbles present/absent] / [midday fogging risk]

• OS Trial: [Brand/design, BC, DIA, Power, Cyl/Axis, Add]

  Settling Time: [minutes]

  Fit Assessment: [centration] / [corneal coverage] / [movement on blink] / [push-up response] (Note edge lift, impingement, conjunctival drag, or tight/loose fit indicators if present)

  Toric-specific: [rotation (degrees and direction)] / [stability after blink] / [axis compensation method if applied]

  Multifocal-specific: [distance/near subjective quality] / [halos/glare] / [dominance strategy if modified monovision]

  GP-specific: [comfort rating] / [movement on blink] / [fluorescein pattern: central, mid-peripheral, edge with timing] / [lid attachment vs interpalpebral position]

  Scleral-specific: [filling solution] / [central vault/clearance with method] / [limbal clearance] / [landing zone alignment] / [bubbles present/absent] / [midday fogging risk]

Over-Refraction and Vision

• OD: Over-refraction [result]; VA achieved [distance, near if relevant] (Note if vision is stable or fluctuating)
• OS: Over-refraction [result]; VA achieved [distance, near if relevant] (Note if vision is stable or fluctuating)

Final Lens Parameters

• OD Final Rx: [Brand/Manufacturer, BC, DIA, Power, Cyl/Axis, Add, replacement schedule]
• OS Final Rx: [Brand/Manufacturer, BC, DIA, Power, Cyl/Axis, Add, replacement schedule]
• Wearing Schedule: [daily wear hours, days per week, overnight permission or restriction]
• Prescription Expiration Date: [date per state requirements]
• (If fit is not finalized, document "Provisional - pending follow-up" and specify criteria required before finalizing)

Dispensing and I&R Training

• [Lenses dispensed today / ordered / trial lenses provided for home use with return precautions]
• [I&R training performed by name/title]; patient demonstrated successful insertion and removal [yes / no]; [barriers addressed if applicable: anxiety, dexterity, plunger use for sclerals]

Assessment

Diagnoses

• [Refractive error diagnoses] (myopia, hyperopia, astigmatism, presbyopia as applicable)
• [Contact lens fitting encounter diagnosis]
• [Ocular surface and adnexal conditions] (dry eye disease, MGD, allergic conjunctivitis, keratoconus, etc., as applicable)

Fit Status

• [Fit acceptable and finalized / Fit acceptable, pending follow-up verification / Fit not acceptable, modified today / Fit deferred with reason]
• (If concerning findings present—staining, infiltrates, neovascularization, hypoxia signs—document severity and reference management in Plan)

Plan

Wearing and Replacement Schedule

• [Specific daily wear hours and adaptation guidance] (For new wearers, include gradual increase instructions)
• [Replacement schedule] (daily disposable / 2-week / monthly)
• [Overnight wear guidance] [permitted with counseling / not recommended / contraindicated]

Lens Care Instructions

• [Solution type and brand]; [rub/rinse instructions]; [case replacement frequency]; [water avoidance instructions]
• (For scleral lenses: filling solution, cleaning/disinfection system, plunger hygiene)
• (For daily disposables: confirm no overnight use, discard after single use)

Patient Education Provided

• [Topics covered: hygiene, water exposure avoidance, sleeping guidance, replacement adherence, signs/symptoms requiring urgent care]
• [Education format: handout / portal message / manufacturer guide]
• [Patient understanding documented via teach-back or acknowledgement] (Do not infer understanding without explicit documentation)

Return Precautions

Patient instructed to stop lens wear and contact the clinic urgently if experiencing pain, significant redness, light sensitivity, discharge, reduced vision, or inability to remove the lens.

Follow-Up

• [Follow-up interval and purpose] (e.g., return in 1–2 weeks for fit/comfort verification and corneal health check)
• [Specialty lens reassessment points if applicable] (vault/landing, vision, comfort, surface deposition)
• [Fitting period status: complete / ongoing / extended with reason]

Prescription Release

• Contact lens prescription provided to patient: [paper / email / portal]
• Patient signed acknowledgement of receipt: [yes / no] (If patient refused, document refusal per practice policy)
• (Retain documentation for minimum 3 years per FTC Contact Lens Rule)

Documentation Notes

• (If a test was not performed, document "Not performed" with brief reason rather than leaving blank)
• (If habitual lens parameters are unknown, document "Unknown" and note impact on fit planning)
• (When carrying forward prior data or importing device values, note the source and date)
• (Clinical interpretations are acceptable when supported by documented objective findings)