RHJVAMC
PROGRAM DESCRIPTION
Residency
in Low Vision and
Primary Care Optometry
Ralph H. Johnson VA Medical Center
affiliated with
SOUTHERN COLLEGE OF OPTOMETRY
MEMPHIS, TENNESSEE
Program Mission
The mission of this residency
program is to provide residents with the clinical education necessary to become
practitioners who are able to deliver low vision/rehabilitative eye care and primary
care optometry, including therapeutic management of ocular disease, in a
multidisciplinary environment. This
program will provide academic and clinical experiences that will enable
residents to expand their knowledge base, strengthen their patient care skills,
and participate in clinical and academic education. Individuals who complete the program are
expected to be able to deliver a high level of clinical care with advanced
sub-specialty Low Vision experience and to serve as optometric educators.
Standard I:
Mission, Goals,
Objectives, Outcomes, and Program Improvement
Goal 1: Provide
the resident with experience in Primary Care Optometry including the role of
ocular diagnostic and therapeutic drugs in the diagnosis and management of
complex ocular conditions.
Objective 1: Provide the resident with adequate
experience and training in the management of complex ocular conditions.
Outcome: The
resident will manage and treat an adequate number of patients with complex
ocular disease presentations.
Measure: Using
data collected from the Encounter Forms (CPRS) and the patient care log
(maintained by the resident), the resident will report quarterly on the numbers
of patients seen with complex ocular disease presentations (as defined as those
patients with three or more ICD-9 diagnoses relating to the eye).
Objective 2: Ensure the resident gains adequate experience
with advanced diagnostic ocular procedures.
Outcome: The
resident will perform and/or interpret advanced diagnostic procedures
(including gonioscopy, fundus contact lens examination, optical coherence
tomography, visual fields, B-scan ultrasonography, and posterior segment
photography) when clinically indicated.
Measure: Using
data collected from the Encounter Forms (CPRS) and the patient care log, the
resident will report quarterly on the number of advanced diagnostic procedures
performed (including gonioscopy, fundus contact lens examination, optical
coherence tomography, visual fields, B-scan ultrasonography, and posterior
segment photography).
Objective 3: Ensure that the resident gains experience
in ordering non-ophthalmic diagnostic tests and procedures necessary for the
evaluation of complex ocular disease
Outcome: The
resident will order non-ophthalmic diagnostic tests and procedures when
clinically indicated.
Measure: Using
data collected from the Encounter Forms and the patient care log, the resident
will report quarterly on the numbers and types of diagnostic tests and
procedures ordered. Review of the resident�s records in accordance with the resident
supervision policy will be used as an opportunity to educate the resident on
the need for special diagnostic tests and procedures on a case-by-case basis
Objective 4: Provide the resident with experience in the
fitting and management of medically indicated prism, or partial ocular
occlusion management of diplopia due to ocular disease
Outcome: The
resident will perform binocular vision evaluations on patients with diplopia
who require the use of ophthalmic prisms or partial ocular occlusion.
Measure: Using
data collected from the Encounter Forms, the resident will report quarterly on
the number and type of ophthalmic prism evaluations performed
Objective 5: Provide the resident with experience in
the triage and management of urgent ocular conditions
Outcome: The
resident will serve as a referral source for urgent eye care consultations
requested of the Eye Clinic
Measure: Using
data collected from the Encounter Forms and the patient care log, the resident
will report quarterly on the number of urgent ocular consultations performed
Goal 2: Provide
the resident with experience in Low Vision / Vision Rehabilitation Optometry to
strengthen clinical competence in delivering Vision Rehabilitative eye care
Objective 1: Ensure the resident performs a minimum
number of low vision/rehabilitative eye care evaluations
Outcome: The resident will perform a minimum of 200 new and/or follow up low vision/rehabilitative eye exams
Measure: Using
data collected from the Encounter Forms and the patient care log, the resident
will report quarterly on the number and type of low vision/rehabilitative eye
exams performed
Objective 2: Expose the resident to a diverse range of low
vision patient presentations
Outcome: The
resident will examine patients with a variety of levels of visual impairments,
representative of the visually impaired population at the Ralph H. Johnson VAMC
and the Storm Eye Institute of the Medical University of South Carolina (MUSC)
Low Vision Rehabilitation Clinic.
Measure: Using
data collected from the Encounter Forms, the resident will report quarterly on
levels of visual impairments encountered as defined by the ICD-9 diagnostic
codes.
Objective 3: Ensure the resident gains experience in
the prescribing of the full scope of low vision devices
Outcome: The
resident will prescribe the full range of non-optical, optical, and electronic
low vision devices as clinically indicated and appropriate for the visually
impaired patient population
Measure: Using
data collected from the Encounter Forms and the patient care log, the resident
will report quarterly on the categories and types of low vision devices
prescribed
Goal 3: Provide
the resident with clinical teaching experiences and training to enable them to
become Attending Optometrists in outpatient clinical or hospital-based primary
eye-care settings.
Objective 1: Ensure that the resident gains experience and
training in functioning as a clinical attending optometrist.
Outcome: The
resident will experience consultative/attending training by discussion and
provide co-attending services for the optometry externs that are doing
rotations at RHJVAMC.
Measure: Using
data collected from the patient care log, the resident will report quarterly on
the number and types of consultation/attending services made for optometry
externs.
Objective 2: Provide the resident with opportunities to
train optometry student externs in clinical procedures in preparation for their
board examinations.
Outcome: The
resident will spend a minimum of 1-2 hours clinical procedural training for
each optometry student extern during their 3 month clinical rotation at
RHJVAMC.
Measure: The
resident clinical schedule will be arranged to provide ample time to provide
attending optometry services and clinical procedural training to the optometry
student externs.
Goal 4: Provide
the Resident with didactic teaching experiences and training to enable them to
become Academic Optometrists or to pursue academic sub-specialty lectureships
Objective 1: Develop the resident�s ability to
effectively share knowledge and disseminate information
Outcome: The
resident will help prepare and present Low Vision Rehabilitation lecture/workshops for Occupational
Therapy Master�s degree students from the College of Health Professions MUSC,
and for Ophthalmology residents from Storm Eye Institute at MUSC
Measure: Documentation
available includes Power Point presentations, and handouts for lectures
presented.
Objective 2: Develop the resident�s instructional and
clinical teaching skills.
Outcome: The
resident will participate in bi-weekly optometric journal club type
presentations and in the clinical supervision and training of optometric
externs.
Measure: A
record will be kept of the topics covered during case review or journal clubs
and the resident will report quarterly on the number of patients where extern
supervision or assistance was provided.
Goal 5: Provide
the Resident with research experiences and training to enable them to not only
appreciate the significance of research in clinical practice, but to engage in,
and conduct worthwhile clinical research and other scholarly activity.
Objective 1: Develop the resident�s ability to
critically evaluate clinical research from the ophthalmic literature.
Outcome: The
resident will read clinically relevant ophthalmic research literature for
discussion with the Program Supervisor and/or staff.
Measure: Each
month, an article from the current issue of �Optometry and Vision Science� will
be chosen by the resident and discussed with the Program Supervisor and/or
staff. A log of these articles will
be maintained by the resident.
Objective 2: Develop the resident�s ability to use library
resources to investigate clinically relevant topics.
Outcome: The
resident will become familiar with methods of library research, including
literature searches.
Measure: The
resident will present a library search based on a chosen �virtual� vision
research question. This �virtual�
project will be used to facilitate discussion of the step-wise development and
conduct of a research question.
Objective 3: Guide and educate the resident as to the
process of preparation of a manuscript of publishable quality.
Outcome: The
resident must prepare a manuscript/case report of publishable quality.
Measure: The
resident will be evaluated quarterly on the progress of his or research paper
or case report manuscript preparation.
Again, the �virtual� project will be used to facilitate discussion of
the step-wise development and conduct of a research project.
Goal 6: Provide
the Resident with community service experiences and training to enable them to
not only appreciate the significance of community service to public health, but
to engage in, and conduct worthwhile community service activities
Objective 1: Develop the resident�s ability to identify
worthwhile projects that will help the community by improving eyecare in some
way.
Outcome: The
resident will have the opportunity to participate in and help organize a vision
screening project that will take place during their tenure. This project is organized and conducted
by the ophthalmology residents from MUSC as a class project each year.
Measure: The
resident will prepare a written after-action report of the project.
Objective 2: Develop an appreciation for providing
community low vision services to the visually impaired, and develop the the
ability to conduct community low vision examinations for the Commission for the
Blind in South Carolina.
Outcome: The
resident will have the opportunity to participate in and help organize a low
vision clinic for the SC Commission for the Blind that will take place during
their tenure.
Measure: The
resident will prepare a written after-action report of the project.
Standard II: Curriculum
The residency program has a
strong clinical emphasis, with a diverse patient base and clinical
experiences. The resident examines
and evaluates low vision patients as part of the clinical Low Vision program, which includes
working directly with a full time vision rehabilitation specialist. The resident also manages patients
with ongoing and chronic ocular diseases as well as fitting contact lenses for
medically indicated conditions such as keratoconus and aphakia. Academic and
didactic activities include a weekly case review session at the VAMC as well as
weekly Grand Rounds at MUSC.
With its emphasis on direct
patient care, the curriculum is designed to provide a significant number of
patient encounters as well to ensure a diverse range of experiences. In the clinic, the resident is given
priority with regard to number of patient encounters, urgent or emergency
consultations, and complex or challenging cases. Approximately 80% of the residents� time
is spent in direct patient care (50% general clinic, 30% low vision), and the
remaining 20% in observation, didactic, research, administrative or academic
activities.
Approximately 30% of the
residents� clinical time will be spent in low vision care as part of the Ralph
H. Johnson�s VAMC�s Low Vision Clinic.
This clinic includes a full time low vision specialist as well as a
fully equipped low vision examination room and comprehensive array of low
vision devices. The resident will
gain experience in full scope of low vision care, including the prescribing of
optical, nonoptical, and electronic and computer based devices., as well as developing a team-based approach to visual
rehabilitation.
The resident will also gain experience in managing
patients with complex ocular disease.
Established patients requiring ongoing care for chronic and/or acute
ocular diseases are scheduled in the resident designated clinic, thus ensuring
that the resident can establish ongoing follow care for his/her own patients.
Ocular disorders managed by the resident include but are not limited to
diabetic retinopathy, glaucoma, macular degeneration, uveitis, anterior segment
disease, peripheral retinal disease, and neurologic disorders. The resident is also given priority for
evaluating patients with acute or emergent eye conditions.
When clinically indicated, the resident orders
diagnostic tests from the laboratory (serology, blood chemistry, etc.), imaging
(X-rays, computed tomography, MRI, etc), peripheral vascular lab (carotid doppler studies), and cardiology (echocardiograms). Within
the Eye Clinic, advanced diagnostic procedures such as ultrasound scanning are
performed independently by the resident after a period of supervised training
by the Program Coordinator. When
necessary, consultative services outside the Eye Clinic can be obtained through
Neurology, Otolaryngology, Vascular Surgery, Infectious Diseases, and other
specialties and subspecialties.
The resident also has the opportunity to
participate in specialty contact lens fitting for medically indicated ocular
conditions. This includes the fitting and follow-up of contact lenses for keratoconus, aphakia, high
myopia, and corneal irregularities or scarring. This clinical opportunity will be made
available for the resident at the MUSC Storm eye Institute contact lens clinic,
typically as a half-day rotation once a month.
The vast majority of patients are examined on an
outpatient or ambulatory basis.
However, the resident also evaluates patients undergoing long-term
intermediate (domiciliary) care, short term inpatient care, and long term
inpatient care (e.g. Nursing Home or Spinal Cord Injury patients) when
requested by their providers.
Inpatient bedside examinations on the hospital wards are also performed
when indicated.
Academic and didactic activities include the
following:
Ophthalmology Grand Rounds
The resident is eligible to attend the case report talks
at the Ophthalmology Resident Grand Rounds at MUSC. Presentations include a
well-researched literature review of the topic, a 15-20 minutes discussion of
the condition involved, and frequently a handout. Ophthalmology grand rounds
are routinely attended by local practitioners in the area. Grand Rounds are
held on the second and fourth Tuesday of each month for ten of the 12 months of
the residency year.
Journal Review
Throughout the year, (monthly) the resident is assigned
journal articles to read which are reviewed and discussed with the Program
Coordinator and Optometry staff.
Bi-Monthly Case Review/Discussion
The first and third tuedsay
afternoon, usually 3:30 – 4:30pm, the resident will lead a case
discussion or review topic discussion regarding interesting cases encountered
during the week.
Monthly Friday Conference
The third Friday afternoon of each month an
academic conference is held in which case presentations and lecture topics are
presented. The presentations are given by the optometry externs, resident or attending
staff.
Ophthalmology sub-specialty rotations
The resident has the opportunity to rotate through
other ophthalmology sub-specialty clinics at MUSC, Storm Eye Institute, depending
on the interests of the resident. These
rotations are scheduled in the second or third quarter of the year and are
designed to give the resident experience with and exposure to secondary eye care
specialties and other supportive disciplines.
�Virtual� Research Project
The resident will identify a research topic of
interest that will become a �virtual� research project. It is to be a �virtual� project in that
it will not be conducted, but will provide a vehicle for instruction of methods
of design and analysis of a research project.
Resident�s manuscript
One of the requirements for the awarding of a
residency certificate is the completion of a manuscript of publishable quality.
This paper may be a case report with literature review or a research project. The Program Coordinator will help the
resident plan for the conduct of any research or case report project to ensure
adequate time is allowed to develop and conduct a worthwhile project. There are options for the resident to
submit a manuscript to the open literature, or to submit a poster or
presentation to an annual optometric continuing education meeting, or to
present their project at the Storm Eye Institute Kiawah Update 2012 meeting
where the ophthalmology residents present their research projects. These options will be carefully explored
and the final decision regarding presentation will depend on the caliber, and
topic of the project.
The educational
objectives of the curriculum are intended to ensure attainment of the mission,
goals, and objectives of the program.
Consequently, each educational objective reflects a specific program
goal. Specifically:
CURRICULUM GOALSProgram Goal 1 |
|
|
Objective: |
Provide the resident with experience in Primary
Care Optometry including the role of ocular
diagnostic and therapeutic drugs in the diagnosis and
management of complex ocular conditions. |
|
Learning
Activity: |
The resident will
provide primary eye care services involving a minimum of 1500 patient
encounters, 60% of which will include obtaining a case history, visual
acuity, refraction, tonometry, and external and internal ocular health
assessment during the encounter. |
|
Outcome: |
The resident will
develop enhanced skills in the management of primary eye care patients. |
Program Goal 2 |
|
|
Objective: |
Provide the resident with experience in Low
Vision / Vision Rehabilitation Optometry to strengthen clinical competence in
delivering Vision Rehabilitative eye care |
|
Learning
Activity: |
The resident will
provide services to a significant number of patients with low vision (approximately
200 patients) and will formulate a diagnosis based on the results of the
procedures performed.
|
|
Outcome: |
The resident will
become highly proficient in the performance and interpretation of basic and
advanced ocular examination techniques on patients with visual impairments,
and will attain advanced skills in the management of these patients. |
Program Goal 3 |
|
|
Objective: |
Provide the Resident with clinical
teaching experiences and training to enable them to become Attending Optometrists
in outpatient clinical or hospital-based primary eye-care settings |
|
Learning
Activity: |
The resident will
learn to interpret ophthalmic fluorescein angiography, B-scan
ultrasonography, anterior segment photography and relevant laboratory and
radiological procedures. The
resident will teach optometry externs the clinical significance of the
specialty testing as they gain expertise in each area. |
|
Outcome: |
The resident will
develop advanced knowledge of specialized diagnostic procedures and
instrumentation. |
Program Goal 4 |
|
|
Objective: |
Provide the Resident with didactic
teaching experiences and training to enable them to become Academic
Optometrists or to pursue academic sub-specialty
lectureships |
|
Learning Activity: |
The resident will
prepare and present didactic style lectures (Power Point computer
presentations) for optometry externs and assist the Program Coordinator in
the presentation of classroom lectures in low vision to the ophthalmology
residents at MUSC. |
|
Outcome: |
The resident will
be able to communicate effectively with optometry students and ophthalmology
residents in providing specialty eye care in the field of low vision. The resident will also prepare case
reports and or journal article reviews for the optometry externs that rotate
through the RHJVAMC. The resident
will be providing small group discussions, small group didactic
presentations, journal article review and discussion – in short, all
those types of teaching activities that produces an experienced educator. |
Program Goal 5 |
|
|
Objective: |
Provide the Resident with research
experiences and training to enable them to not only appreciate the
significance of research in clinical practice, but to
engage in, and conduct worthwhile clinical research and other
scholarly activity. |
|
Learning
Activity: |
The resident will
have several options to decide about before committing to one particular
project. Initially, the Program
Coordinator (who has experience with all the potential types of projects)
will conduct one-on-one discussions covering the following options: a case report format of an interesting
case or cases encountered during clinic; a literature review of a topic the
resident is deeply interested in; a clinical research project conducted with
the Program Coordinator (who would help get the project thru the review
process and human subjects approval).
|
|
Outcome: |
The resident will
produce a publishable quality manuscript designed as either
a case report, literature review, or clinical research project. Presentation of the project will be
both written and oral. It must be
completed as a written submission to a journal for review and publication,
and as a verbal presentation (at Kiawah in the Spring, and/or at SCO resident
project day or both, or as a small group discussion project report at
RHJVAMC). |
Program Goal 6 |
|
|
Objective: |
Provide the Resident with community
service experiences and training to enable them to not only
appreciate the significance of community service to
public health, but to engage in, and conduct worthwhile
community service activities |
|
Learning
Activity: |
The resident will have the opportunity to
participate in and help organize a vision screening project that will take
place during their tenure. This
project is organized and conducted by the ophthalmology residents from MUSC
as a class project each year.
There is also an opportunity to organize and participate in a
community low vision clinical project through the Commission for the Blind. |
|
Outcome: |
The resident will
develop skills in organizing and providing specialty eye-care to the community. |
A. All
applicants must complete and return the Southern College of Optometry
application forms by January 15. Supporting documents should be submitted to
the Director of Residency Programs of Southern College of Optometry no later
than January 31. This program will
use the Optometric Residency Matching Service. Applicants must complete the ORMS
application and forward it to the ORMS as directed in the application.
Applicants are responsible for ensuring that all supporting documentation is
submitted to each entity involved, e.g., the College, ORMS, and the residency
site if required.
B. Applicant
must have earned an O.D. degree, or will have earned such a degree by the time
of matriculation from an accredited school/college of optometry.
C. Applicant
will furnish an official transcript from his/her school/college of
optometry. An applicant should have
a cumulative grade point average greater than 3.0 on a 4.0 scale in the
professional optometric curriculum.
D. Applicant
must pass all parts of the National Board of Examiners in Optometry
examinations required for South Carolina license and furnish official
transcripts when available.
E. Three
letters of recommendation are required.
F. A
brief essay stating reasons for applying to this program.
G. A
personal interview is required.
H. Southern
College of Optometry affirms that all residency candidates will be evaluated
without regard to sex, race, color, creed, national origin or disabilities.
All applicants selected
for admission must sign a standard letter of intent.
Each residency is one
calendar year in length, commencing in July.
The resident is eligible
for thirteen days annual leave.
A. The
resident is defined as an employee of the Ralph H. Johnson VAMC and the
residency stipend is paid by the VAMC.
No tuition or fees are applicable.
B. The resident should for apply for optometric
license in at least one of the fifty states prior to the beginning of the
residency.
C. Professional liability protection for residents for work
done at the Ralph H. Johnson VAMC is provided under the Federal Tort claims
act.
D.
Health insurance
benefits are available through RHJ VAMC Federal Health Insurance Benefits
Program. Residents also have the
option of purchasing health insurance through the affiliate, SCO. Leave benefits include 13 days annual
leave and 13 days sick leave at a rate of 4 hours per pay period. Additional educational leave, or
authorized absence, is typically allowed.
Many factors are weighed before granting such leave, but history has
shown that this has been generous with
prior approval of the residency site-director in conjunction with the
DRP and the Chief of the Optometry Service.
E. Residents will have access to the Internet for
research purposes, the RHJVAMC and the MedicalUniversity of South Carolina
Medical School libraries, and remote access to library search capabilities at Southern
College of Optometry.
A. The resident is required to deliver clinical
services at a level that is satisfactory to the Residency Supervisor, the
Residency Committee, Director of Residency Programs, and the SCO and Ralph H.
Johnson VAMC administrations.
Normal clinic hours are from 8:00 A.M. until patient care is completed,
usually around 4:30 P.M., Monday through Friday. The resident is expected to be present
during all working hours, except attending conferences and doing study or
research. The resident will carry a
pager while in the clinic in order to address urgent eye problems. However, optometry residents are not
required to answer calls during off-duty hours.
B. The resident is required to keep a record of
patient contacts. Cases will be
reviewed periodically by the Supervisor of the Residency Program, the Director
of Residency Programs, and the Residency Committee.
C. The resident is required to write a publication quality
paper based on original research, literature review, or a clinical case. The resident will be encouraged submit
this paper to an approved journal.
D. The resident is expected to perform in a professional
manner in the delivery of patient care services and to observe those
proprieties of conduct and courtesies that are consistent with the rules and
regulations governing Ralph H. Johnson VAMC.
E. The resident is required to participate in and
complete the requirements set forth in the curriculum.
F. Upon successful completion of the Residency
Program, the Residency Supervisor and the Director of Residency Programs will
recommend the granting of certification to the Vice President of Academic
Affairs.
H. Any resident accepted for training can be dismissed,
without receiving a certificate of completion, for infractions of the rules and
regulations of the Ralph H. Johnson VAMC or those set forth by Southern College
of Optometry, or for any action which jeopardizes the safety of patients,
personnel, or physical facilities.
A residency stipend will be provided for the year of training paid by Ralph
H. Johnson VAMC. The total
financial compensation package is $31,965.
Other employment (moonlighting)
during the residency year is allowed by the Ralph H. Johnson VAMC optometry
program provided that the resident does not let outside employment interfere
with ANY residency activities and that such employment does not take place
during normal working hours.
Residents who choose to moonlight will not be allowed to leave their
post at the Ralph H. Johnson VAMC during normal office hours or before patient
care duties are finished. Using
sick leave or annual leave to work in the private sector is prohibited.
The residency program at the Ralph H. Johnson VAMC will be fully accredited
by the Council on Optometric Education, 243 N. Lindbergh Blvd., St. Louis, MO
63141, 314-991-4100.
Upon satisfying all the requirements for completion of the program as
determined by the Supervisor of the Residency Program and the Director of the
Residency Programs, a Certificate of Completion will be awarded to the resident
by Southern College of Optometry.
The resident reports to the Supervisor of the residency program. The Supervisor reports directly to the
SCO Director of Residency Programs who in turn reports directly to the Vice
President of Clinical Programs at Southern College of Optometry.
FOR FURTHER INFORMATION, PLEASE CONTACT:
Cheryl
E. Ervin, O.D.
Director,
Residency Programs
Southern
College of Optometry
1245
Madison Avenue
Memphis,
TN 38104
(901)
722-3201
email:
cervin@sco.edu
Resident_______________________________________________
Summary period: From _____________
Through _____________
I. Comprehensive
General Eye Examinations
Age
0-10 _______
11-20 _______
21-30 _______
31-40 _______
41-50 _______
51-60 _______
61-70 _______
71-over _______ Level of Involvement
TOTAL _______1 P____S____O____
II. Brief
& Limited Visits _______2 Level of Involvement
P____S____O____
III. Contact
Lens Procedures (NOT included in categories 1 & 2)
Fittings
& Brief
office Re-fittings visits
(PC,
Disp., etc.)
Soft
Lens ___________ ___________
Rigid
Gas Permeable ___________ ___________
Other ___________ ___________
TOTALS ___________3 ___________4
Level of
Involvement Level
of Involvement
P____S____O____ P____S____O____
Sub-categories
(included in categories 3 & 4)
Spherical ______ Bifocal ______
Toric ______ Monovision ______
Keratoconus ______ Other ______
IV. Binocular
Vision Examinations (NOT included in categories 1
& 2)
Vergence
problems ________
Accommodative
problems ________
Strabismus ________
Oculomotor
dysfunction ________
Amblyopia ________
Visual
perceptual ________ Level of
Involvement
TOTAL ________5 P____S____O____
V. Special
Visits (screening patients, patients seen while performing special procedures,
etc.)
Patients
seen on vision screenings ________
__________________________________ ________
__________________________________ ________
Level of
Involvement
TOTAL ________6 P____S____O____
VI. Objective-related
Encounters (included in categories 1, 2, 3, 4, 5, & 6)
Ophthalmic
angiography analyses ________
Laboratory/radiological orders/analyses
________
Systemic
disease consults ________
Low
vision encounters ________
VII. Contact
Lens Procedures (included in categories 1, 2, & 5)
Fittings
& Brief
office Re-fittings visits
(PC,
Disp., etc.)
Soft
Lens ___________ ___________
Rigid
Gas Permeable ___________ ___________
Other ___________ ___________
Sub-categories
(included in above totals)
Spherical ______ Bifocal ______
Toric ______ Monovision ______
Keratoconus ______ Other ______
VIII. Problems
of binocular vision & ocular motility (included in categories 1, 2,
3, 4, 5, & 6)
Amblyopia
Refractive ________
Strabismic ________
Congenital ________
Other ________
Strabismus
Esotropia ________
Exotropia ________
Vertical ________
Visual
perceptual
Visual motor dysfunction ________
Visual memory ________
Laterality/Directionality ________
Accommodative
Insufficiency/Inflexibility ________
Convergence
Insufficiency/Excess ________
Divergence
Insufficiency/Excess ________
Phoria
related problems
Esophoria ________
Exophoria ________
Vertical ________
IX. Ocular
Disease (included in categories 1, 2, 3, 4, 5, & 6)
Adnexa ________
Lacrimal
system ________
Conjunctiva ________
Cornea ________
Anterior
chamber & angle ________
Glaucoma
suspect ________
Glaucoma ________
Iris ________
Lens ________
Vitreous ________
Retina ________
Choroid ________
Optic
nerve ________
X. Systemic
Disease (included in categories 1, 2, 3, 4, 5, & 6)
Hypertension ________
Diabetes ________
Degenerative
joint disease ________
Cardiovascular
(excluding HTN) ________
CVA/Neurological ________
Dermatological ________
Endocrine ________
ENT ________
Gastrointestinal ________
Hematologic ________
Immunological/Allergic ________
Infectious/Parasitic ________
Musculoskeletal/CT/Collagen ________
Neoplastic ________
Nutritional/Metabolic ________
Psychological/Psychosomatic ________
Pulmonary ________
Renal/Urologic ________
Other ________
XI. Referrals & Follow-up visits
Referrals
Optometry ________
General
medicine ________
Ophthalmology ________
Other ________
Follow-up
visits (included in categories 1, 2, 3, 4, 5, & 6)
________
Level of
Involvement
TOTAL PATIENT ENCOUNTERS* ________ P____S____O____
*Sum of 1, 2, 3, 4, 5, & 6.
Remember: The sum of P, S, and O for each category should equal the
total encounters for that category. The total of all categories (1 through 6)
should equal the total encounters above.
I
certify that this document is an accurate record of my activities for the
stated period.
_____________________________________________
Date_____________
Resident signature
XII. List other activities such as CE, presentations given, conventions attended, etc.