Optometry: Step-by-Step Guide on How to Write SOAP Notes

Written by SOAPNoteAI Editorial Team · Updated July 2026

Optometry documentation captures the comprehensive eye examination, the workhorse encounter of primary eye care. A well-written optometry SOAP note records visual acuity, the manifest refraction and resulting prescription, intraocular pressure, a slit-lamp evaluation of the anterior segment, a dilated fundus examination, and binocular vision status, then ties these measured findings to an assessment and a plan for correction, ocular health management, or referral. Unlike a surgical ophthalmology note, the optometric note centers on refractive care, contact lens management, functional vision, and the detection-and-referral role that defines the optometrist's scope.

This guide provides step-by-step instructions for documenting optometric encounters, from a routine annual comprehensive exam to a contact lens fitting, a binocular vision workup, or a diabetic eye examination. Precise, quantitative documentation of acuity, refraction, and pressure is essential for tracking change over time, supporting prescription accuracy, justifying medical necessity, and providing medicolegal protection.

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What Makes Optometry Documentation Unique

Optometry differs from other specialties in several key documentation aspects:

1. Bilateral, Quantitative Findings: Nearly every finding is recorded separately for the right eye (OD), the left eye (OS), or both eyes (OU), and many are numeric values (acuity, refraction, IOP) that must be exact.
2. The Refraction Drives the Note: The manifest refraction and the spectacle or contact lens prescription that results from it are the central deliverable of most optometric visits, comparable to a procedure note in other fields.
3. Standardized Ophthalmic Notation: Snellen acuity, sphere/cylinder/axis refraction, Jaeger near notation, cup-to-disc ratios, and clock-hour localization are a specialty vocabulary that must be used consistently.
4. Detection and Referral Role: Optometry is often the first point of contact for ocular and systemic disease, so documentation must clearly capture screening findings and the boundary at which care is referred to ophthalmology.
5. Functional and Binocular Vision: Cover testing, phorias, convergence, stereopsis, and accommodation are documented in a way that few other specialties require.
6. Progression Tracking: Refractive error, IOP, cup-to-disc ratio, and retinal findings are compared to baseline and prior visits to detect change.

Subjective Section (S)

In an optometry SOAP note, the Subjective section captures the reason for the visit, the ocular and visual history, and the functional impact of any complaint. Laterality and timing should be specified for each symptom.

Subjective Section (S) Components

1. Chief Complaint:

   • The primary reason for the visit, in the patient's words, with laterality when relevant
   • Example: "Blurred distance vision in both eyes and eyestrain when reading, worsening over the past year."

2. History of Present Illness (Ocular):

   • Onset, duration, laterality, and progression of the visual complaint
   • Quality (blur, glare, distortion, double vision), timing (constant, near, distance, end of day)
   • Associated symptoms (headache, eyestrain, redness, tearing, foreign-body sensation)
   • Example: "Gradual blurring at distance over 12 months, worse when driving at night, with eyestrain and frontal headache after prolonged near work."

3. Visual and Refractive History:

   • Current spectacle and contact lens wear, age of the current prescription, and satisfaction with it
   • History of refractive surgery, amblyopia, strabismus, or vision therapy
   • Example: "Wears single-vision spectacles obtained two years ago; no contact lens wear; no history of eye surgery or amblyopia."

4. Contact Lens History (when relevant):

   • Current lens type, brand, modality, wearing schedule, replacement schedule, and care system
   • Comfort, wear time, and any prior complications
   • Example: "Two-week disposable soft lenses worn daily for 10 to 12 hours, replaced monthly instead of biweekly; occasional end-of-day dryness."

5. Ocular History:

   • Prior eye conditions, injuries, infections, or treatments
   • Family history of glaucoma, macular degeneration, retinal detachment, or strabismus
   • Example: "No prior ocular disease. Family history significant for glaucoma in the patient's mother."

6. Systemic History Relevant to the Eyes:

   • Diabetes, hypertension, thyroid disease, autoimmune conditions
   • Medications with ocular effects (steroids, anticholinergics, hydroxychloroquine, tamsulosin)
   • Example: "Type 2 diabetes for 6 years; reports last HbA1c around 7.2 percent per primary care. Takes metformin and lisinopril."

7. Occupational and Visual Demands:

   • Occupation, screen and near-work hours, driving, hobbies, and visual environment
   • Example: "Works at a computer approximately 8 hours daily; drives at night for a long commute."

8. Allergies and Current Medications:

   • Drug and topical allergies, and current ocular and systemic medications
   • Example: "No known drug allergies. Uses over-the-counter artificial tears as needed."

Tips for Optometry Subjective Documentation:

• Specify laterality and distance-versus-near for every visual complaint.
• Record the age and type of the current correction; it frames the refractive assessment.
• Capture near-work and screen demands, which support recommendations and medical necessity.
• Document the reported systemic control (for example HbA1c) for diabetic and hypertensive patients.

Example of a Subjective Section for Optometry

Objective Section (O)

The Objective section in optometry is built from measured, bilateral data. Accuracy and standardized notation are essential because prescriptions and downstream medical decisions depend on these exact values. Record findings by eye (OD, OS, OU) throughout.

Objective Section (O) Components

1. Visual Acuity:

   • Distance and near acuity for each eye, with the testing condition noted (without correction, with correction, or pinhole)
   • Snellen notation for distance; Jaeger or equivalent for near
   • Example: "Distance cc: OD 20/40, OS 20/50, improving to OD 20/20, OS 20/20 with pinhole."

2. Pupils:

   • Size, shape, reactivity, and the presence or absence of a relative afferent pupillary defect (APD)
   • Example: "PERRL, no APD (pupils equal, round, reactive to light; negative afferent pupillary defect)."

3. Extraocular Motility and Confrontation Fields:

   • Ocular motility and versions, and confrontation visual fields for each eye
   • Example: "Extraocular movements full and smooth OU. Confrontation fields full to finger counting OD and OS."

4. Cover Test and Binocular Assessment:

   • Cover test at distance and near, near point of convergence, and stereopsis
   • Example: "Cover test: orthophoria at distance, mild exophoria at near. Near point of convergence to the nose. Stereopsis 40 seconds of arc."

5. Manifest (Subjective) Refraction:

   • Sphere, cylinder, and axis for each eye, add power if applicable, and the best-corrected acuity achieved
   • State the method (manifest, cycloplegic, over-refraction)
   • Example: "Manifest refraction OD -2.75 -0.50 x 090 (20/20), OS -3.00 -0.75 x 085 (20/20), add +1.50 OU (near 20/20)."

6. Intraocular Pressure (IOP):

   • Value for each eye with method and time of measurement
   • Example: "Goldmann applanation tonometry: OD 15 mmHg, OS 16 mmHg at 10:20 AM."

7. Anterior Segment / Slit-Lamp Examination:

   • Lids and lashes, conjunctiva, cornea, anterior chamber depth (for example Van Herick), iris, and lens
   • Example: "Lids and lashes clear, conjunctiva quiet, cornea clear OU, anterior chamber deep and quiet (Van Herick grade 3), lens clear."

8. Dilated Fundus Examination:

   • Dilating agents and time, then vitreous, optic disc (cup-to-disc ratio), macula, vessels, and periphery for each eye
   • Example: "Dilated with tropicamide 1% and phenylephrine 2.5% at 10:35 AM. Discs pink and distinct, cup-to-disc ratio 0.3 OD and OS."

9. Additional Testing (when performed):

   • Fundus photography, OCT, visual fields, corneal topography, central corneal thickness, gonioscopy
   • Example: "Macular OCT obtained OU; automated visual field performed OD and OS."

Comprehensive Eye Exam Objective Template

Example of an Objective Section for Optometry

Assessment Section (A)

The Assessment section synthesizes the subjective and objective findings into a problem list: the refractive diagnosis, the ocular health status, and any conditions requiring management or referral. Each problem should be stated by eye when laterality applies and supported by the findings above.

Assessment Section (A) Components

1. Refractive Diagnosis:

   • The refractive error identified, by eye, and the functional impact
   • Example: "Compound myopic astigmatism, both eyes, with early presbyopia."

2. Ocular Health Assessment:

   • Status of the anterior segment, optic nerve, macula, and retina
   • Example: "Anterior and posterior segments healthy aside from evaporative dry eye; optic nerves and maculae within normal limits."

3. Problem List with Clinical Reasoning:

   • Each active problem, its severity, and supporting evidence
   • Example: "1) Myopia and presbyopia, correctable to 20/20. 2) Evaporative dry eye, mild, based on rapid tear break-up and symptoms. 3) Diabetes without retinopathy at this exam."

4. Risk Stratification (when relevant):

   • Glaucoma suspect status, diabetic or hypertensive risk, family history
   • Example: "Glaucoma risk elevated by family history; IOP and cup-to-disc ratio currently normal, no field or OCT defect. Monitor."

5. ICD-10 Considerations:

   • Diagnoses coded to the appropriate specificity and laterality; the clinician confirms final codes
   • Example: "Documented diagnoses support codes for myopia, astigmatism, presbyopia, and dry eye; confirm laterality and specificity at coding."

6. Comparison to Prior Findings:

   • Change in refraction, IOP, cup-to-disc ratio, or retinal status versus baseline
   • Example: "Refraction increased by approximately -0.50 D in each eye compared with the prescription from two years ago; IOP and discs stable."

Optometric Assessment Approach

For systematic assessment, consider:

For Refractive and Functional Problems:

• Type of refractive error and best-corrected acuity
• Presbyopic status and near demands
• Binocular vision diagnosis such as convergence insufficiency when symptomatic

For Ocular Surface and Anterior Segment:

• Dry eye subtype and severity
• Allergic, infectious, or inflammatory conditions
• Contact-lens-related complications

For Ocular and Systemic Disease Screening:

• Glaucoma suspect versus established disease
• Diabetic and hypertensive retinal findings graded by severity
• Cataract and macular changes with visual significance

Example of an Assessment Section for Optometry

Plan Section (P)

The Plan section documents the correction prescribed, ocular health management, patient education, referrals, and follow-up. In optometry, the released spectacle or contact lens prescription and the follow-up interval are the core deliverables, and any referral to ophthalmology must be explicit.

Plan Section (P) Components

1. Spectacle Prescription:

   • Distance and near powers, add, prism, and any lens recommendations (progressive, anti-reflective, photochromic, blue-light, occupational)
   • Example: "New spectacle prescription released with a progressive addition lens and anti-reflective coating for computer and driving."

2. Contact Lens Plan (when relevant):

   • Lens type, parameters, wearing and replacement schedule, and care system, or a referral for a fitting
   • Example: "Trial daily disposable multifocal lenses dispensed; return for a fit evaluation in two weeks."

3. Ocular Health Management:

   • Treatment for identified conditions such as dry eye, allergy, or infection
   • Example: "Begin preservative-free artificial tears four times daily, warm compresses, and lid hygiene for evaporative dry eye; reassess in six to eight weeks."

4. Diagnostic and Monitoring Plan:

   • Additional testing, imaging, or surveillance intervals
   • Example: "Baseline fundus photography and macular OCT retained for diabetic monitoring; repeat dilated exam annually."

5. Referrals:

   • Specialty, provider, urgency, and the specific finding prompting referral
   • Example: "No referral required at this visit; documented threshold for referral to ophthalmology if retinopathy or a glaucomatous change develops."

6. Patient Education:

   • Diagnosis explanation, prescription use, digital eye strain and the 20-20-20 rule, UV protection, and diabetic eye health
   • Example: "Counseled on presbyopia and progressive lens adaptation, the 20-20-20 rule for computer use, and the importance of annual diabetic eye exams and glycemic control."

7. Follow-Up:

   • Timing and purpose of the next visit and any interval safety-net instructions
   • Example: "Return in one year for a comprehensive diabetic eye examination, or sooner for any sudden vision change, flashes, floaters, or eye pain."

Optometric Treatment and Management Categories

Refractive Correction:

• Single-vision, bifocal, and progressive spectacles
• Occupational and computer-specific lenses
• Soft, rigid gas-permeable, multifocal, toric, and scleral contact lenses
• Myopia management options for pediatric patients

Ocular Surface and Anterior Segment Management:

• Artificial tears, lid hygiene, and warm compresses for dry eye
• Topical treatment of allergic, bacterial, or inflammatory conditions within scope
• Punctal occlusion and prescription dry-eye therapy

Functional Vision:

• Prism prescription
• Vision therapy for convergence insufficiency and accommodative dysfunction

Screening, Monitoring, and Co-Management:

• Glaucoma surveillance and co-management
• Diabetic and hypertensive retinal monitoring
• Cataract and macular degeneration monitoring with referral when visually significant

Example of a Plan Section for Optometry

AI-Assisted Documentation for Optometry

AI-powered documentation tools can reduce the charting burden of a high-volume optometry clinic by capturing the spoken narrative of an exam and structuring it into a SOAP note. Optometry encounters are highly quantitative, however, so the value of AI is in efficiently capturing history, reasoning, education, and plan, while the measured numbers require deliberate dictation and human verification.

How AI Can Help with Optometry Documentation

• History capture: Transcribes the chief complaint, ocular and refractive history, contact lens wear, and systemic history efficiently
• Assessment and plan narrative: Structures the problem list, patient education, and follow-up plan
• Consistency: Encourages complete, bilateral documentation and standardized ophthalmic terminology
• Efficiency: Reduces documentation time so clinicians can move between exam lanes without falling behind on charting

What AI Captures Well in Optometry

• Chief complaint and history of present illness
• Ocular, refractive, and contact lens history
• Systemic history and medications relevant to the eyes
• Assessment reasoning, patient education, and follow-up plans
• Referral rationale and return-precaution counseling

What Requires Careful Review

• Visual acuity values for each eye and testing condition (confirm every Snellen and near value)
• Manifest refraction: sphere, cylinder, axis, and add for each eye
• Intraocular pressure values and method
• Cup-to-disc ratios and any graded retinal or macular findings
• Contact lens parameters: base curve, diameter, power, brand, and modality
• Laterality (OD, OS, OU) on every finding

AI should never infer or fill in an acuity, refraction, intraocular pressure, cup-to-disc ratio, or contact lens parameter that was not actually measured and stated. A missing value should be left blank for the clinician rather than estimated.

Tips for Using AI with Optometry Documentation

1. State every value with laterality: "Right eye 20 over 20, left eye 20 over 25" rather than "vision is good"
2. Dictate refraction in full: "Right eye minus two point seven five, minus zero point five zero, axis ninety, add plus one point five zero"
3. Speak intraocular pressure with the method: "Goldmann applanation, right eye fifteen, left eye sixteen"
4. Verbalize disc and macula findings by eye: "Cup-to-disc ratio zero point three in each eye, maculae flat with a crisp foveal reflex"
5. Read back contact lens parameters and verify them against the order before signing
6. Verify all measured values against your instruments and phoropter before finalizing the note

For more details, see our complete AI-Assisted Documentation Guide.

Documenting Refraction, Spectacle, and Contact Lens Prescriptions

The refraction-to-prescription workflow is the signature of optometric documentation. A defensible note distinguishes the manifest refraction obtained at the phoropter from the final prescription that is released, records the best-corrected acuity that each refraction achieves, and captures every parameter needed to fabricate spectacles or dispense contact lenses accurately. Because a transposed axis, a reversed cylinder sign, or an incorrect base curve can produce an unwearable correction, each value must be transcribed exactly as measured and ordered.

Spectacle Prescription Elements

• Sphere, cylinder, and axis for each eye, with the cylinder in a consistent sign convention (minus-cylinder is standard in optometry)
• Add power for presbyopic and multifocal prescriptions
• Prism and base direction when prescribed
• Pupillary distance and any fitting measurements for progressive lenses
• Lens recommendations (single-vision, bifocal, progressive, occupational, anti-reflective, photochromic)
• Expiration date per state regulations

Contact Lens Prescription Elements

• Lens design and material (soft, silicone hydrogel, rigid gas-permeable, toric, multifocal, scleral)
• Base curve, diameter, and power for each eye
• Cylinder and axis for toric lenses; add for multifocal lenses
• Brand or design name and the specific replacement and wearing schedule
• Care system and expiration date

Example Refraction and Prescription Documentation

Free Optometry SOAP Note Template

Speed up your documentation with our comprehensive optometry SOAP note template. This template includes all essential elements of a comprehensive eye examination, from visual acuity and refraction through dilated fundus findings, prescriptions, and follow-up planning.

More Template Resources

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