• Perform all elements identified by a bullet (*)
• Document every element in a box with a shaded border
• Document at least one element in each box with an unshaded border

Eyes


* All elements must be documented.

• Test visual acuity (does not include determination of refractive error)
• Gross visual field testing by confrontation
• Test ocular motility including primary gaze alignment
• Inspection of bulbar and palpebral conjunctive
• Examination of ocular adnexae including lids (e.g., ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes
• Examination of pupils and irises including shape, direct and consensual reaction (afferent pupil), size (e.g., anisocoria) and morphology
• Slit lamp examination of the corneas including epithelium, stroma, endothelium and tear film
• Slit lamp examination of the anterior chambers including depth, cells and flare
• Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex and nucleus
• Measurement of intraocular pressures (except in children and patients with trauma or infectious disease)  

Ophthalmoscopic examination through dilated pupils (unless contraindicated) of:

• Optic discs including size, C/D ratio, appearance (e.g., atrophy, cupping, tumor elevation) and nerve fiber layer
• Posterior segments including retina and vessels (e.g., exudates and hemorrhages)

Neurological/
Psychiatric

Brief assessment of mental status including:

• Orientation to time, place and person
• Mood and affect (e.g., depression, anxiety, agitation)