Vision Screening Documentation

Header Fields

Date/Time: [Date and time]

Setting: [Clinic well visit / School screening / Community program / Other: specify]

Indication: [Routine age-based screening / Rescreen after prior unable or fail / Parent or teacher concern: specify] (If complaint-driven or symptomatic, clearly state this is not screening-only.)

Performed by: [Role and name/credential of screener] (If interpreter used, include name and language.)

Pre-Screen Conditions

Correction status: [Wears corrective lenses: yes/no] | [Testing performed with habitual correction in place: yes/no]

Cooperation level: [Cooperative / Limited / Uncooperative]

Barriers affecting validity: [None / Developmental delay / Language barrier / Acute illness / Anxiety / Other: specify] (Keep brief for clearly normal, cooperative screenings; expand if results are abnormal or validity is questionable.)

(For borderline, failed, or untestable results, document: Test distance verified: [yes/no] | Environment adequate: [yes/no])

Screening Modality and Results

Modality used: [Visual acuity (optotype-based) / Instrument-based screening / Both]

Visual Acuity (Optotype-Based)

(Include this section only if optotype testing performed.)

Optotype/chart: [LEA Symbols / HOTV / Sloan / Snellen / Other: specify] | Test distance: [Distance] | Occlusion method: [Adhesive patch / Occluder glasses / Spoon occluder / Other: specify]

Results:

• OD (Right): [20/XX / Untestable: reason]
• OS (Left): [20/XX / Untestable: reason]
• OU (Binocular): [20/XX] (Optional; do not use alone for pass/fail.)

Pass/Fail criteria used: [Criterion set or guideline] (Common pediatric thresholds: age 3 pass if 20/50 or better each eye; age 4 pass if 20/40 or better; age 5+ pass if 20/32 or better. Refer if ≥2-line interocular difference even if each eye meets threshold.)

Optotype screening outcome: [Pass / Fail / Untestable]

Instrument-Based Screening

(Include this section only if instrument-based screening performed.)

Device: [Photoscreener / Autorefractor / Binocular scanner] | Manufacturer/Model: [Specify] | Bilateral: [Yes / No]

Device outcome: [Pass / Refer / Inconclusive / Unable to obtain] | Quality/Confidence indicator: [Value, if available]

Discrete device findings: [Estimated refractive values, anisometropia, gaze asymmetry, media opacity, or other risk factors as reported by device] (Only include fields actually reported. Attach device printout separately when feasible.)

(Do not label Inconclusive or Unable to obtain as Pass. If device indicates Refer, document as Refer without over-interpreting numeric estimates unless clinician interpretation with defined criteria is part of your workflow.)

Results Summary

Summary: Vision screening performed using [visual acuity / instrument-based screening / both]. Outcome: [Pass / Fail / Untestable].

Abnormal findings: [Eye(s) involved], [key numeric result or device Refer outcome], [validity caveats if any] (Include only if applicable. Do not assign diagnoses from screening results.)

Plan

If Pass

• Routine follow-up per preventive schedule: [Timeframe or per age-based guideline]

If Fail/Refer

• Referral destination: [Pediatric ophthalmology / Optometry / Community vision program] | Urgency: [Routine 4–12 weeks / Expedited 1–2 weeks / Urgent if red flags]
• Order placed: [Yes / No] (If no, reason: [Family declined / Already established with eye care / Will self-refer / Other])
• Follow-up plan: [Tracking method and timeline for referral completion]
• Caregiver notification: [In-person / Phone / Portal] on [Date] (Document that screening is not diagnostic and a comprehensive eye exam is needed.)

If Untestable

• Rescreen plan: [Yes / No] | Timeframe: [Specify] | Planned adjustments: [Different occlusion method, shorter distance, alternative optotype, interpreter, improved environment, etc.]
• Referral indicated: [Yes / No] (Consider referral for repeated untestable results, high-risk child, or concerning behaviors.)
• Caregiver notification: [In-person / Phone / Portal] on [Date] (Document that screening is not diagnostic and comprehensive evaluation may be needed.)