Documentation

Now, let's review how to document that information. I've included an autorefractor keratometer sample print out here for you for reference. You will see the date and the time listed. You’ll also see the right eye with corresponding measurements, the left eye with corresponding measurements, and the pupillary distance, in both distance and near. It will also indicate what make and model of instrumentation are you using. So, it gives an abundance of information. You’ll see the autorefractor measurements for the sphere, cylinder, and the axis. It lists the three measurements and then it gives an average of the three listed in parentheses. This is the information that you’ll notate in the patient's chart.

On the next section of the auto refractor keratometer print out is the corneal curvature. R1 references the horizontal meridian or minor meridian and R2, references the vertical meridian or major meridian. And then you have an average of both. You will document both of these numbers within the patient’s chart.