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Doctor Of Optometry
20-25 minutes

Template for Documenting Low Vision Template

The Low Vision Record Template by s10.ai is a vital resource for optometrists performing detailed low vision evaluations. This template assists clinicians in meticulously documenting a patient's eye and medical history, social and functional difficulties, and visual acuity assessments. It features sections for noting contrast sensitivity, current eyewear, and low vision aids used or provided. The template guarantees a comprehensive analysis of risk factors and offers a structured approach to patient care, including prescriptions, guidance, and referrals. Perfect for optometrists, this template optimizes the assessment workflow, improving patient care and management.

3,150 uses
4.5/5.0
D
Dr. Emily Carter
Template Structure

Organized sections for comprehensive clinical documentation

Low Vision Evaluation
Subjective
(Include patient's presenting complaint and reason for attending the low vision clinic)
Patient Name: "[Full Name]"
Date of Birth: [DOB]
Gender: [Gender]
NHS Number: [NHS Number]
Address: [Address]
Telephone: [Telephone]
Referral and Access
New or existing Low Vision Patient (has the patient been seen previously)
Referral Source: [Referral source] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)
Transportation: [Transportation method] (Only include if explicitly mentioned, otherwise leave blank)
Waiting Time: [Waiting time] (Only include if explicitly mentioned, otherwise leave blank)
Ocular History
(Summarise patient's ocular history, including diagnosis, onset, progression and previous treatments)
Eye Conditions: [Document relevant findings]
Previous Ophthalmic Interventions: [e.g., surgery, laser] (Only include if explicitly mentioned, otherwise leave blank)
Medical History
(Briefly summarise the patient's general health, including relevant systemic conditions and current medications.)
General Health: [Mention health conditions and relevant systemic history]
Medications: [List medications]
Social and Functional History
(Describe the patient's living situation, support network, and daily activities. Detail any difficulties they are experiencing due to their visual impairment.)
Social Situation: [Describe situation]
Reported Difficulties: [Mention specific challenges, e.g., mobility, lighting, reading]
Current Support: [Detail any support or services received to date]
Patient's Goals: [Specify what the patient hopes to achieve with the low vision assessment]
Objective
Visual Acuity
(Document unaided and aided visual acuities. If pinhole is used, note this.)
Unaided Distance VA:
Right Eye: [6/] [V/A]
Left Eye: [6/] [V/A]
Aided Distance VA:
Right Eye: [6/] [V/A]
Left Eye: [6/] [V/A]
Near VA: [Specify VA and working distance]
Contrast Sensitivity
(Document the Contrast Sensitivity measurements. Specify the test used and whether it was measured binocularly or monocularly.)
Test Used: [Pelli Robson, Hamilton Veale, MARS, other] (Only include if explicitly mentioned, otherwise leave blank)
Method: [Binocular, Right Eye, Left Eye]
Results:
Binocular: [Log CS Score] (Only include if explicitly mentioned, otherwise leave blank)
Right Eye: [Log CS Score] (Only include if explicitly mentioned, otherwise leave blank)
Left Eye: [Log CS Score] (Only include if explicitly mentioned, otherwise leave blank)
Current Spectacles
(Document the patient's current spectacle prescription.)
Right Eye: [Sph] [Cyl] [Axis] [Prism] [Base]
Left Eye: [Sph] [Cyl] [Axis] [Prism] [Base]
Date of Last Eye Exam: [Date]
Low Vision Evaluation
(Document the low vision aids tried, including magnification, type, and VA achieved. Note which aids were dispensed.)
Current LVAs: [Document existing aids and VA achieved]
LVAs Tried: [List devices tried and VA achieved]
LVAs Dispensed: [List devices issued today]
Risk Factors
(Assess and document any risk factors that may impact the patient's safety, independence, and well-being.)
Sensory Impairments: [Deafness, Hearing Loss, Blindness] (Only include if explicitly mentioned, otherwise leave blank)
Living Situation: [Lives alone, Lives with family, Lives in assisted living] (Only include if explicitly mentioned, otherwise leave blank)
Mobility: [Risk of falls, Uses mobility aids] (Only include if explicitly mentioned, otherwise leave blank)
Safety: [Risk of burns, Difficulty with medication management] (Only include if explicitly mentioned, otherwise leave blank)
Psychosocial: [Signs of isolation, depression, anxiety] (Only include if explicitly mentioned, otherwise leave blank)
Plan
(Summarise the recommendations, including any spectacle or tint prescriptions, advice given, and referrals made.)
Spectacle/Tint Prescription: [Specify issued or prescribed items]
Advice Given: [Include details about lighting, contrast, eccentric viewing, coping strategies]
Referrals: [Specify if referred to Ophthalmologist, GP, Social Services, Support Groups, etc.]
Registration: [Specify if advice on registration provided, or if already registered as SI/SSI]
Follow-up Appointment: [Specify date or timeframe, if applicable]
Practitioner Notes
(Include any other relevant observations, modifications made to the assessment, or additional information.)
Additional Observations: [Detail any further findings or relevant information]
"Practitioner Signature:" [Signature]
"Date:" [Date]
AI Instructions:
Subjective, Ocular History, Medical History, Social and Functional History: Please compose these sections using information gathered from the session, prioritising the patient's own words and reported experiences.
Objective: Accurately record the numerical data provided.
Risk Factors: Specifically note any mentioned risk factors. If none are mentioned, this section can be left blank.
Plan: Focus on concisely summarising the actions taken and advice provided during the session.
Do not hallucinate information. Only populate if present in the transcripts provided.
Verbatim sections are important, please do not alter them.
Sample Clinical Note

Example of completed documentation using this template

Low Vision Assessment
Subjective  
Patient Name: "John Smith"  
Date of Birth: 15 March 1950  
Gender: Male  
NHS Number: 1234567890  
Address: 123 Vision Lane, Sight Town, ST1 2AB  
Telephone: 01234 567890  
Referral and Access  
New or existing Low Vision Patient: New  
Referral Source: GP  
Transportation: Public Transport  
Waiting Time: 2 weeks  
Ocular History  
Eye Conditions: Age-related macular degeneration diagnosed 5 years ago, progressive vision loss  
Previous Ophthalmic Interventions: Cataract surgery in both eyes  
Medical History  
General Health: Hypertension, Type 2 Diabetes  
Medications: Lisinopril, Metformin  
Social and Functional History  
Social Situation: Lives with spouse, supportive family  
Reported Difficulties: Difficulty reading small print, issues with mobility in low light  
Current Support: Receives assistance from local vision support group  
Patient's Goals: Improve reading ability and enhance mobility  
Objective  
Visual Acuity  
Unaided Distance VA:  
Right Eye: 6/60  
Left Eye: 6/48  
Aided Distance VA:  
Right Eye: 6/36  
Left Eye: 6/30  
Near VA: N12 at 40 cm  
Contrast Sensitivity  
Test Used: Pelli Robson  
Method: Binocular  
Results:  
Binocular: 1.25 Log CS  
Current Spectacles  
Right Eye: +2.00 -1.00 x 90  
Left Eye: +2.50 -0.75 x 85  
Date of Last Eye Exam: 1 November 2023  
Low Vision Assessment  
Current LVAs: Handheld magnifier, VA improved to N8  
LVAs Tried: Stand magnifier, VA achieved N6  
LVAs Dispensed: Stand magnifier  
Risk Factors  
Sensory Impairments: None  
Living Situation: Lives with family  
Mobility: Uses a cane for stability  
Safety: Difficulty with medication management  
Psychosocial: Signs of mild depression  
Plan  
Spectacle/Tint Prescription: Prescribed reading glasses with +3.00 add  
Advice Given: Recommended increased lighting, use of contrast-enhancing filters, and eccentric viewing techniques  
Referrals: Referred to Ophthalmologist for further evaluation, advised to contact Social Services for additional support  
Registration: Advised on registration as SI  
Follow-up Appointment: 6 months  
Practitioner Notes  
Additional Observations: Patient motivated and receptive to using low vision aids  
"Practitioner Signature:" Dr. s10.ai  
"Date:" 1 November 2024
Clinical Benefits

Key advantages of using this template in clinical practice

  • The Low Vision Assessment template is an essential tool for clinicians aiming to deliver comprehensive care to patients with visual impairments. This template is meticulously designed to capture critical patient information, including subjective complaints, ocular and medical history, and social and functional challenges. It facilitates a thorough evaluation of visual acuity, contrast sensitivity, and current spectacle prescriptions, ensuring that all aspects of the patient's visual health are addressed. Clinicians can document the effectiveness of low vision aids and assess risk factors impacting patient safety and independence. The template also supports the development of personalized care plans, including spectacle prescriptions, advice on coping strategies, and necessary referrals. By adopting this template, healthcare professionals can enhance patient outcomes through structured and detailed assessments, ultimately improving the quality of life for individuals with low vision.
Frequently Asked Questions

Common questions about this template and its usage

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