NHS GOS Sight Test

- Issued prescription for glasses [Describe the sphere, cylinder, axis, distance prism, visual acuity, near add, near prism, and near visual acuity for OD and OS] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Dispensing recommendations [Spectacles recommended] (Does the patient require glasses. Describe whether the prescription is stable, and include details for single vision distance, reading, bifocals, varifocals, high index lenses, toughened lenses, office spectacles, or myopia control lenses. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Sight test type: [What exemption does the patient fall under for an NHS sight test] (The following NHS recall intervals should be used: GOS Sight Test Primary Eye Examination Minimum Intervals: Under 16 – All patients: 1 year 16–59 years – All patients: 2 years 60–69 years – All patients: 2 years 70 & over – All patients: 1 year Any age – Diabetic: 1 year Any age – Glaucoma: 2 years 40 & over – Glaucoma family history (not in monitoring scheme): 1 year Any age 40 & over – Ocular hypertension (not in monitoring scheme): 1 year Under 7 – BV anomaly or corrected refractive error: 6 months 7–under 16 – BV anomaly or rapidly progressing myopia: 6 months Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - NHS Early Retest Code: [Why the patient is being tested before the normal recall interval] (The following early test recall codes should be referenced: 1 – Patient is at risk of frequent changes of prescription for reasons not requiring medical referral or for reasons already known to a medical practitioner. 2 – Patient has pathology likely to worsen, for example age-related macular degeneration, cataract, corneal dystrophy, or congenital anomalies. 3 – Patient has presented with symptoms or concerns requiring ophthalmic investigation: 3.1 – Resulting in referral to a medical practitioner 3.2 – Resulting in issue of a changed prescription 3.3 – Resulting in either no change or no referral (the patient’s record should indicate any symptoms shown to support this category of claim if necessary) 4 – Patient requiring: 4.1 – Complex lenses 4.2 – Corrected vision of less than 6/60 in one eye 5 – Patient has: 5.1 – Presented for a sight test at the request of a medical practitioner 5.2 – Is being managed by an optometrist under the GOC referral rules (e.g. suspect visual fields not confirmed on repeat, or abnormal IOP with no other significant signs of glaucoma) 5.3 – Been identified in protocols as needing to be seen more frequently because of risk factors 6 – Other unusual circumstances requiring clinical investigation Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Treatments: [Describe any medications, laser, or surgical interventions previously undergone or planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Follow-Up: [Describe the interval until the next visit and any conditions for a sooner return] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Patient Education: [Describe any information given to the patient about diagnosis, treatment, or prognosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Referrals: [Describe any referrals made to other specialists] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) -Current Glasses [Describe the power of the patient’s current glasses, whether obtained from previous records or focimetry, including sphere, cylinder, axis, distance prism, visual acuity, near add, near prism, and near visual acuity for OD and OS] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) Subjective: - Chief Complaint: [Describe the brief reason for the visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - History of Present Illness: [Describe onset, duration, severity, and character of the visual complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Past Ocular History: [Describe history of eye diseases, surgeries, treatments, and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Medical History: [Describe relevant systemic conditions affecting ocular health] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Medication History: [Describe current ocular and systemic medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Allergies: [Describe medication and substance allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Family Ocular History: [Describe eye diseases in the family] (Report negatives only if explicitly mentioned. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Family Medical History: [Describe systemic diseases in the family] (Report negatives only if explicitly mentioned. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Social History: [Describe tobacco use, alcohol use, occupational hazards, hobbies, or sports] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) Objective: - Vision: [Describe unaided visual acuity for OD and OS] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Pinhole Vision: [Describe pinhole visual acuity for OD and OS] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Visual Acuity: [Describe visual acuity with current glasses or contact lenses for OD and OS] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Retinoscopy: [Describe retinoscopy findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Intraocular Pressure: [Describe measurement method and values for OD and OS, and whether values fall within normal, borderline, referral, urgent, or emergency ranges] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) Anterior Segment: [Describe slit-lamp findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Lids and lashes: [Describe lid and lash findings, stated as OU if not discussed individually] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Cornea: [Describe corneal findings, stated as OU if not discussed individually] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Anterior Chamber: [Describe cells, flare, or angle findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Pupil Reactions: [Describe pupil reactions or abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) -Media: [Describe vitreous findings, stated as OU if not discussed individually] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) -Lens: [Describe lens findings, stated as OU if not discussed individually] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) Posterior Segment: - Macula: [Describe macular findings, stated as OU if not discussed individually] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Peripheral retina: [Describe peripheral retinal findings, stated as OU if not discussed individually] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Optic Discs: [Describe optic disc findings including C/D ratio, colour, rim, and RNFL, stated as OU if not discussed individually] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Retinal Vessels: [Describe retinal vessel appearance and artery-to-vein ratio, stated as OU if not discussed individually] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) [Findings from fundus examination including method used and whether dilating drops were used] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Additional Tests: [Describe results of visual fields, OCT, or fluorescein angiography] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) Assessment: - Binocular Refraction: [Describe binocular vision findings including fixation disparity, phorias, suppression, and motility] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Foveal Suppression: [Record foveal suppression test results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - Refraction Notes: [Describe refraction refinement or balancing findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write as a list.) - [Describe diagnosis with ICD-10 code as stated by clinician] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not invent or infer a diagnosis.) - [Describe any differential diagnoses as stated by clinician] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not invent or infer diagnoses.)