Optometry Pediatric Eye & Vision Examination Note

Encounter

Date/Time: [Encounter date and time]
Location: [Clinic/location]
Visit Type: [comprehensive pediatric eye exam / follow-up / problem-focused]

Patient: [Patient full name] | DOB: [DOB] | Age: [Age in years and months] | Corrected Age: [Corrected age if premature infant, otherwise omit]
Parent/Guardian Present: [Name and relationship]
Historian: [Historian source] ([Reliability note if limited by age or communication])
Interpreter: [Language and interpreter name/ID] (Omit if not used)
Referral Source: [Referral source and screening results if applicable] (Omit if self-referred)

Chief Complaint

[Chief complaint in parent/patient words] (For routine asymptomatic exams: "No visual concerns reported" is acceptable)

History of Present Illness

[Onset, duration, frequency, triggers, associated symptoms, functional impact on school/reading, prior treatments and responses, failed screening details if applicable] (Include for concern-driven visits; omit section entirely for routine asymptomatic exams)

History

• Ocular/Vision History: [Prior eye exams, current/previous glasses, patching or atropine history, vision therapy] (Document "Not obtained: [reason]" if unavailable)
• Birth/Perinatal History: [Gestational age, birth weight, NICU, ROP screening/treatment] (Include if <6 years or risk factors present; document "Not obtained: [reason]" if unavailable)
• Pertinent Medical History: [Neurodevelopmental diagnoses, systemic conditions, prior surgeries] (Document "Not obtained: [reason]" if unavailable)
• Medications and Allergies: [Current medications with ocular relevance; allergies with reactions] (Document "None" or "Not obtained: [reason]")
• Family Ocular History: [Amblyopia, strabismus, high myopia, congenital ocular conditions] (Document "None" or "Not obtained: [reason]")
• Developmental/Educational History: [Developmental milestones, school grade, IEP/504, teacher concerns, visual behaviors] (Include when relevant to presenting concern; document "Not obtained: [reason]" if unavailable)
• Lifestyle Factors: [Average daily outdoor time, near-work/screen habits] (Include for myopia counseling)

Examination

(Document test conditions and methods throughout. For any test not completed, document "Unable" or "Deferred" with reason and plan inline rather than omitting. Complete key alignment testing prior to cycloplegia when possible.)

Cooperation and Testability

[good / fair / poor]; [factors affecting reliability]

Visual Acuity

• Correction Status: [uncorrected / habitual correction / trial frame / pinhole]
• Test Distance: [Distance] | [Near]
• Optotype/Method: [LEA / HOTV / Snellen / Teller / Cardiff / fix-and-follow] [crowded / single] [matching / naming / preferential looking]
• Results: OD: [VA] | OS: [VA] | OU: [VA]
• Infant/Preverbal Function: [Fixation quality, following behavior, fixation preference] (Include for preverbal children)

Refraction

• Non-cycloplegic: [Retinoscopy / Autorefraction / Subjective] OD: [values] | OS: [values]
• Cycloplegic Refraction: Agent: [agent and concentration] | Time instilled: [time] | Time measured: [time] | Method: [Retinoscopy / Autorefraction] | OD: [values] | OS: [values] (If deferred: document reason and plan)
• Final Prescription: OD: [Sph/Cyl x Axis] | OS: [Sph/Cyl x Axis] | PD: [value] | Rationale: [amblyopia treatment / symptom relief / functional needs] (Include if prescribed)

Alignment and Binocular Vision

• Cover Testing: Distance: [method, magnitude/direction in prism diopters, control] | Near: [method, magnitude/direction, control]
• Ocular Motility: [Versions/ductions, restrictions, overactions/underactions, nystagmus]
• Stereopsis: [Randot / Frisby / TNO / other]: [result]
• Near Point of Convergence: Break: [cm] | Recovery: [cm] (Include when near symptoms or learning concerns exist)

Accommodation and Vergence

(Include when near-work or learning concerns exist)

• Accommodative Function: [Amplitude, Facility, MEM/Nott response as relevant]
• Vergence/Phoria: [Distance and near phorias, fusional vergence ranges as relevant]

Ocular Health

• External/Anterior Segment: [Penlight / Slit lamp]: [Lids/lashes, conjunctiva, cornea, AC, iris, lens findings]
• Pupils: [Size, reactivity, RAPD assessment]
• IOP: [iCare / Tono-Pen / Applanation] OD: [mmHg] | OS: [mmHg] (If deferred: document reason and plan)
• Posterior Segment: [Dilated / Undilated] via [BIO / DO / Fundus camera]: [Disc, macula, vessels, periphery findings] (If not dilated: document reason and plan)

Ancillary Testing

[Color vision, visual fields, OCT, axial length, topography, photos as performed with results] (Omit section if none performed)

Assessment

• [Problem 1]: [Diagnosis/clinical impression]
• [Problem 2]: [Diagnosis/clinical impression] (Add problems as needed)

Amblyopia Risk Assessment: Risk factors: [interocular VA difference / significant refractive error or anisometropia / strabismus / media opacity / prematurity / family history - note present or absent]. Status: [amblyopia diagnosed / amblyopia suspected / no evidence of amblyopia today / cannot rule out due to incomplete exam].

Plan

(Address each problem; document counseling provided and parent/guardian understanding confirmed)

[Problem 1]: [Diagnosis]

• Treatment: [Glasses / Patching / Atropine / Vision therapy / Other with regimen]
• Instructions: [Wear schedule, adaptation guidance, precautions, school accommodations]
• Follow-up: [Interval] for [purpose]
• Referrals: [Specialist/service] - [routine / urgent / emergent] (Include if applicable)
• Counseling: [Topics discussed; parent verbalized understanding]

[Problem 2]: [Diagnosis]

• Treatment: [Details]
• Instructions: [Details]
• Follow-up: [Interval and purpose]

Anticipatory Guidance

• Myopia Risk Counseling: [Outdoor time recommendations, near-work ergonomics, screen breaks]
• Eye Safety: [Protective eyewear, UV protection]
• Return Precautions: [New constant eye turn, leukocoria, sudden vision change, severe headache with vomiting, acute red eye, trauma]