1. SOS Eyeglasses Universal Optometric Intake & Exam Form
Capturing Optometric Mission Data To Enhance the Global Fight Against Uncorrected Refractive Error & Preventable Ocular Disease

2. Universal Optometric Mission Intake & Exam Form
Why use this form vs. other existing forms
The goal of a universal exam form is to create a consistent process that can support multiple global mission goals
Collecting exam data that can be analyzed and shared across the Optometric & Opticianry communities
The specific format allows for the scanning and data conversion of large amounts of information collected during the screening, exam and visual acuity or refractive error solution process
The forms are mailed to a central processing facility where they are scanned, analyzed by conversion software and turned into exam and encounter data
When completed the mission leader is ed a report detailing the results of their mission trip
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3. Universal Optometric Mission Intake & Exam Form
How is the data used
The data is secured by stripping away the names of the patients upon export
The available data can be used for the following
University research projects
Allowing for improved mission preparation
Determining what prescriptions to bring inventory for
Pre-made glasses and readers
Pre-cut lenses for Ready to Clip or assemble on site eyeglass solutions
Stock lens inventory if the mission has edging capability
Better understanding of the level of Men’s, Women’s, Adult and Children’s frames needed to fit the population that will be at the mission
All data will be captured in a manner that allows for analysis and review by country or region
This is an important step in addressing the issue of uncorrected refractive error on a global basis

4. The process
The form itself can be printed from the downloadable PDF file
When printing, make sure that you select the “Actual Size” option as the data conversion rate will decline if you shrink the pages.
The form follows the most common steps in an optical mission and is meant to be completed as the patient progresses through the process
When the mission is complete, carefully package all of the forms and send them in to:
Bob Stein at 20/20 Quest
c/o National Vision, Inc.
2435 Commerce Avenue
Building 2200
Duluth, GA
Make sure you fill out and include the processing cover sheet so all of your mission information is properly categorized and so that you are ed you mission summary report

5. Getting started
On the surface, it seems like a tremendous amount of information, but it is really no more than you collect today
The key is to assign responsibility to each mission station to fill in their part of the form and to have that form travel with the patient
The form is laid out to follow the screening & exam process in these steps
Demographic & Basic Health Information Capture
Current Rx (if available)
Autorefracted or Retinoscopy Rx
Visual Acuity (Aided & Unaided)
Intraocular Pressures, Blood Pressure, Blood Sugar Levels
Doctor Rx
Ocular Health, Diagnosis, Treatment & Referrals

6. Station 1 - Demographic & Basic Health Information Capture7 1 2 3
Jr.
The information that goes into each of the areas is self explanatory, but there are some rules about filling out the form so the computer can scan it later
Each box can contain only one letter or number. The scanning and conversion system looks in each of the narrower boxes for one letter or number, while in the wider boxes it looks for more than one letter or number
It does not matter if you use a pen or pencil, but pencils are better as you can make corrections
Note that the date is in the international format (YYMMDD)
“Bubbles” are used frequently throughout the form as they are very accurate when converting this paper form to data (as shown in the Urban / Rural section)
Penmanship does matter as the better the handwriting the better the conversion to data
These basic rules of completing the form apply throughout, please make sure everyone understands them
It is highly recommended that you have everyone complete a practice form on themselves prior to seeing patients

7. Station 1 - Demographic & Basic Health Information Capture7 1 2 3 D O M 2 3 J O H N N Y B G O O D E
Jr.
There are some specific areas that are important to getting the best data capture
The Country ID is uses the United Nations Country Codes to identify where the mission is taking place
In this example, if the mission was in the Dominican Republic, you would record DOM
The Patient # has a dual role; it serves as the intake number so you can sequence the patient flow, but it is also the unique ID number that identifies the patient when the form is converted to data.
In this example, the patient is the 23rd patient of the mission, so you would write in 0023
For Patient names, addresses and phone numbers, just remember to write one letter per box, and write clearly

8. Station 1 - Demographic & Basic Health Information Capture8 1 6 9
It is recommended that this section also be completed at the point of original intake
Due to the nature of the health questions, you may need a more knowledgeable person to ask these questions
Due to space restrictions on the form here is one more area that needs to be completed on the middle of the form on the right side. We do want to know if the patient speaks English, and if they are literate.
Both of these pieces of information help streamline the rest of the process
We want to capture as much information as possible to allow for future data analytics, and improved mission support

9. Station 2 – Recording Current, Auto or Retinoscopy Rx5 8 1 1 1
The process of recording Rx results is basically identical for the Current Rx, Auto or Retinoscopy Rx, and Doctor Rx’s
The Plus or Minus bubble must be filled in to record a valid Rx
Any Sphere Power up to 8.75 can be recorded using the bubbles
If the Sphere Power is 9.0 Diopters or greater, you will write it in the (>= 9D) box
Add .25, .50 or .75 to the Sphere Rx by filling in the appropriate bubble
For Cylinder Power, simply write in the number, and bubble in the quarters if needed
Write in the numbers for Axis and Prism
Bubble in the appropriate Add Power and quarters
Write in the PD
The OD Rx shown would be captured as: Sphere -3.50, Cylinder -1.50, Axis 110, Prism None, Add +1.25, PD 58
The only difference between the Current Rx and the Auto or Retinoscopy Rx is the need to fill in

10. Station 3 – Visual Acuity, Intraocular Pressure, Blood Pressure & Sugar15
110/80 40 20 60 30 18
4.3 40 20 60 30
The results of Visual Acuity, Intraocular Pressure, Blood Pressure & Blood Sugar levels are all hand written in
Again, clear handwriting is essential to getting high levels of clean data conversion
Note that the Blood Pressure and Blood Sugar charting area is on the bottom left of the form
Station 4 – The Doctors Exam, Rx & Glasses use recommendation 58 1
105
As you can see this works like any other Rx entry
The difference is you need to bubble in the recommended use of the glasses
In this case, both a near and distance pair will be given to the patient
The Doctor Rx 1 is for the distance pair in this example, so the appropriate bubble is filled in

11. Station 4 – Let’s Try An Rx With a sphere power of 9.0 or greater58 10 1
105
1.0 BU 1
110
1.0 BU
As you can see most of this works like any other Rx entry. BUT….
In this example the Sphere Power is 10.50D and the bubbles only go up to 8
In this case you don’t bubble in the Sphere Power, but write it down in the (>= 9D) section
The system will use the handwritten Sphere Power to record the integer portion of the Sphere Rx
Use the bubbles for the Sphere Power quarters as usual, only handwrite whole (integer) numbers
As you can see in the example the OD and OS Sphere Powers are recorded independently of each other (OD: -10.5D and OS -8.75D)
Now let’s add in some Prism
Prism is a tight fit on the form, so when it is necessary, make sure you write clearly
Prism will be one of the data elements captured for subsequent analysis, but primarily as it being present in the prescription or not
Of course, it needs to be legible at the mission for the manufacture of custom eyeglasses

12. Station 4 (continued) – Ocular Health, treatment & referral
Severe Dry Eye
The doctor (or their scribe) will bubble in all of the areas that are appropriate
This area covers a wide span of issues, but all are clinical in nature 3 4
For the PERRLA section, write in the size and bubble Normal, Slow or Fixed
Sign the form
Write in any notes. The Notes section is captured an as image or picture so as long as you write within the box your notes will be captured.

13. What to do with the forms
Collect up all of the forms and prepare them to be sent in for processing and data capture
If forms are too wrinkled or torn they probably won’t scan, so at some point, have one of your newbies copy over the damaged forms
This activity goes well with friends and beverages…….
The original forms need to be sent in for processing (not copies)
Make sure you fill out and include the processing cover sheet so all of your mission information is properly categorized and so that you are ed you mission summary report
The Processing Cover Sheet allows the system to tag each patient record with the Chapter, mission leader, date, location etc.. To enhance future analysis
When the mission is complete, carefully package all of the forms and send them in to:
Bob Stein
20/20 Quest
2435 Commerce Avenue
Building 2200
Duluth, GA

14. Complete the Master Data Import Information sheet, package and ship