Patient Education

Patient Eye Exam History

A majority of patients do not understand the importance of their eye exam history and what it can show. Every time a patient visits an eye doctor’s office, it is required by law for there to be a record kept for a certain amount of time, which can vary due to local laws, but this record becomes part of a patient’s eye exam history. From this an optometrist or ophthalmologist can see changes in eye prescription through a period of time, look at visual problems in several aspects like peripheral and binocular, and check if eye conditions or diseases were present before. All this information can help eye doctors determine, during future eye exams, if the patient has had a major change in vision, if disease like cataracts may have developed since the last exam because the patient’s vision is less clear, and if there are any abnormalities or other conditions present.

What is in an Eye Exam History?

Patient eye exam profiles contain a lot of information about each visit including prescriptions, test results, any diagnostic methods used. The basic information of the patient, including age at the time of exam and date of the exam are necessary recordings. A patient’s current eye acuity like 20/ 20 vision or 20 / 60 vision in the left, right, and both eyes combined is included in the history charts. Tests results for peripheral vision, glaucoma, and possibly other diagnostic tests are included. If the eye doctor has to perform special diagnostics using medication, or prescribes therapeutic medication, all these are recorded on the patient’s eye charts.

Notes, comments, and even treatment recommendations from the eye doctor are also a part of the patient’s eye exam history. These notes by eye doctors are for their protection, as well to verify the steps and outcome of each exam. This helps protect against lawsuits and allegations that they did not perform adequate examinations and treatments. Eye doctors who do not maintain adequate records can be fined by state boards. An example is Herri C. Park, an Illinois optometrist who was fined $500 for failure to maintain adequate patient records, and Tom R. Masters, an Illinois optometrist who was fine $750 for insufficient patient records.

Transferring Exam Charts

Patients often times change eye doctors, but many do not have their eye history charts transferred along with them, which can cause lots of issues. Patients who have had prior eye diseases and conditions should have their eye exam history transferred to any future eye specialist they see, in order to minimize any possible problems that may arise, and to inform the new eye doctor of current issues. Those without major eye issues should still have their eye charts transferred to any new optometrist or ophthalmologist they see, so that they are well informed of the patient’s conditions, and can spot any major changes in vision and test for certain diseases. Transferring eye history charts usually requires just asking the current eye care provider the name of the past one, or filling out the complete form during the visit. Patient’s can ask the eye doctor to request their eye exam history.

Patient Eye History Example

Let’s start with a patient who has had no vision problems in the past, has 20 / 20 vision, and has changed eye doctors. The patient goes to a new doctor without providing or requesting an eye exam history chart. The new eye doctor sees that visual acuity is 20 / 80 and intraocular pressure is slightly above normal. Some eye doctors may disregard this as just average changes, but an eye exam history chart can help an optometrist or ophthalmologist see that there was a big change in visual acuity and a first time increase in intraocular pressure, which could be signs of other major eye diseases or conditions. This is just one example of how a patient’s eye history can be used.


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