Optometry Refraction/Rx Check Note

Visit Information

Date: [Date]

Provider: [Provider name and credentials]

Location: [Clinic/Location]

Visit Type: Refraction / Rx Check

Reason for Visit: [Rx recheck after new glasses / Vision change / Post-procedure refraction / Other]

Source of History: [Patient / Parent / Caregiver] (Only include if not the patient)

(This visit focuses on refractive complaints, eyewear verification, and spectacle prescription determination—not a comprehensive ocular health examination.)

Chief Complaint & History

[Refractive complaint narrative] (Include onset and timeline, relation to new glasses if applicable, laterality and viewing distance affected, symptom quality [blur/distortion/ghosting/headache/asthenopia/dizziness], wear pattern and adaptation context, and modifying factors. Include brief red-flag screening [sudden loss, flashes/floaters, pain, diplopia, neurologic symptoms] or note if addressed in same-day comprehensive exam. Add pertinent ocular history only when relevant to the refractive complaint.)

Optical Verification

Lensometry (problem glasses):

• OD: [sphere/cylinder/axis; add; prism if present]
• OS: [sphere/cylinder/axis; add; prism if present]
• Comparison to written Rx: [matches written Rx / discrepancy identified—specify]

Frame & Fit: [vertex distance, pantoscopic tilt, segment height, PD/OC placement, or "fit appropriate"]

(If lensometry or fit assessment was not performed, document why.)

Examination

Visual Acuity

• Habitual correction: OD: [VA]; OS: [VA]; OU: [VA]
• Problem glasses: OD: [VA]; OS: [VA]; OU: [VA] (Include only if applicable)
• Pinhole: OD: [VA]; OS: [VA] (Include only if VA reduced)
• Near VA: [test distance and correction]; OD: [VA]; OS: [VA]; OU: [VA] (Include only if near complaint)

Refraction

• Starting point: [habitual Rx / autorefraction / retinoscopy]
• Manifest refraction: OD: [sphere/cylinder/axis] → [VA]; OS: [sphere/cylinder/axis] → [VA]
• Binocular balance: [method and result] (If not performed, state reason)
• Over-refraction through problem glasses: [findings; whether symptoms resolved] (Include only if applicable)
• Near add: [method]; Add: [power] → Near VA: [VA] (Include only if presbyopic)

Binocular/Accommodative Testing: [cover test, vergences, NPC, accommodative findings as relevant] (Include only if symptoms suggest binocular vision involvement; document quantitative values)

Ocular health screening: [Performed briefly / Deferred]; [no new symptoms / new symptoms addressed separately]. Last comprehensive exam: [date] (Only include screening status; full findings belong in comprehensive exam note.)

Assessment

1. [Primary diagnosis] — [evidence linking complaint to findings]
2. [Refractive status] — [myopia/hyperopia/astigmatism/presbyopia as measured]
3. [Contributing factors] — [fabrication error / frame-fit issue / adaptation to Rx change / binocular vision stress] (Include only if supported by findings)

(Distinguish objective measurements from clinical interpretation.)

Plan

Final Spectacle Rx (Include if issuing new prescription)

• OD: [sphere/cylinder/axis; add; prism]
• OS: [sphere/cylinder/axis; add; prism]
• Purpose: [distance / near / PAL / computer / task-specific]
• Expiration: [per state law]

Comparison to habitual: [clinically significant changes and what was communicated to patient]

Intervention: [Remake indicated—specify changes / Frame adjustment—specify / Adaptation trial—specify hours/day, expected vs concerning symptoms, safety guidance / No change needed—rationale]

Follow-up: [timeframe; return precautions for red-flag symptoms]

Rx Release: [Prescription provided to patient / Patient declined copy—documented]

Patient Education: [counseling provided] (Document when education delivered regarding adaptation expectations, PAL behavior, or task-specific limitations.)