Introduction Copy

Introduction

The primary objective of occupational vision screening is to determine the vision of the worker. The results have significant influence on the fitness for duty, diagnosis, and treatment plan for workers. In occupational vision screening the final outcome of the results will determine whether or not a worker is fit for work or not. Sometimes the results will be used as part of a submission for compensation due to vision loss. Therefore, recording and interpretation of the results is a critical step for the vision screening technician. When interpreting vision screening results, the report guides the technician on the result, but the application of the action and exclusion criteria determines whether a worker is fit or not.

Vision screening technicians are not required to make a diagnosis but will need to identify whether the results are normal or abnormal and will need to manage these results correctly. To do this effectively and accurately, the technician must interpret the results of the full assessment done.
Good quality, accurate and professional medical records are an essential component of safe and effective occupational healthcare. The main function of medical records is to facilitate4:

Continuity of care
Record decision made regarding care and management
Trend analysis
Prevent exploitation and
Helps in litigation

Poor-quality medical records make it difficult to defend a clinical negligence claim or a disciplinary inquiry; it is also a good indicator of poor clinical practice. Medical records should contain all the significant information that members of the healthcare team, or future carers, will need to be sufficiently informed about the worker’s past and current clinical assessments (includes vision screening) and treatment and relevant family and social history, lifestyle, and beliefs6.

Compulsory elements of clinical records relating to vision screening2:

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For a full and detailed guide on medical records read or download the MPS Guide on Medical Records in South Africa.

https://www.medicalprotection.org/docs/default-source/pdfs/booklet-pdfs/sa-booklets/medical-records-in-south-africa—an-mps-guide.pdf?sfvrsn=cda14eac

How to record the results of the tests done

Vision screening starts with the physical examination and ends with the various visual acuity tests. These results must now be recorded on a report accurately. Because the procedures for recording and reading vision screening are not universal or standardised this section is a guideline only and the technician will need to clarify local procedures and requirements where they work.

Before interpreting the vision screening results, it is important to remember that this (interpretation) cannot be done by only looking at the report, interpretation requires analysis of all the information available at the time of the assessment which includes the following:

Full medical, surgical, and social history.
Full occupational history.
The physical eye examination and visual acuity tests.
The ocular history.
The comparison to other vision screening results.
The minimum risk requirement.
If any further investigation is necessary.
If health education was given specifically to eye health care.
When to come back for re-test.

1. Record of Basic Information about the Worker

Record the demographics and personal information for the worker.
Record the time, date, and place of the consultation.
Record the psychosocial, medical, and occupational history.
Record the ocular history
Record the worker’s exposures at home and work.

2. Record of Basic Information about the Worker

Record the physical examination of the eyes noting colour, symmetry, function, and abnormalities.
Note the colour of the iris.

3. Record of Basic Information about the Worker

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4. Record Visual Acuity Tests – Non-Automated Assessment

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Table 9.1 Recording the results of the Colour Vision Test using the Ishihara Plates

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Record Visual Acuity Tests –Automated Assessment

When recording results for an automated test it is important to use the correct documentation. Each vision screener has a specific recording sheet and this changes for makes and models. Some examples are provided below but this is not a comprehensive list. Remember automated vision screening cannot perform a physical examination or some of the function tests therefore these non-automated tests must still be performed and recorded by the technician.

This is the only section of record-keeping in vision screening that is different to the non-automated recording.
Complete the demographic data required on the specific recording sheet, this is in addition to the vision questionnaire.
Conduct the tests with and without glasses / contact lenses and record the results on the record sheet for the vision screener.
The normal and abnormal criteria is listed on the vision screening instruction slides and on some of the recording sheets, but these may not meet the fitness for duty criteria which is detailed in the action and exclusion criteria for a specific company. See chapter 10 for details. It is recommended that the results are recorded and interpreted as per the recording sheet, the OHNP will then match these results to the action and exclusion criteria to determine fitness for duty.
Refer to the various examples of automated test records below as examples of completed and uncompleted forms. See figures 9.2

Figure 9.2 Example of a Titmus Instruction Sheet – Slide 13

Note the following:

The type of test done.
The question to ask.
The correct answer required for a normal outcome
The pass and fail criteria.
How to record the result.
See the Titmus Landot Record Form to see how to record the results on figure 9.6 and 9.7

5. Management and referral

Once the tests have been recorded in the correct format the technician can start interpreting the results and deciding what to do with the worker. Action and exclusion criteria, visual guidelines and standards, legislation, and specific industry requirements guide the technician on what is an acceptable result for the position the worker is employed in. Refer to Chapter 10 for the management of abnormal results. If all the results are normal, then the OHNP will make the worker fit for duty without referring the worker for further assessment or to the OMP for a fitness for duty adjudication. Detailed notes of referrals, decisions and outcomes must be written clearly on the vision screening report or record and in the clinical notes. A decision needs to be made by the OHNP on whether the worker can continue working until feedback from a referral or not. If the worker is not fit sick leave will need to be given and this must be recorded on the file.

6. Health Education and feedback to the worker

Before the worker leaves the vision screening area the technician must provide the worker with feedback on the results, whether normal or abnormal, whether referral may be necessary and when to return to the clinic for further testing. The OHNP will also need to advise the worker on the possible effects of abnormal vision on fitness for duty. Health education must be provided with a special focus on preventing eye injuries and protecting vision as covered in Chapter 5 – Preventing Eye Injuries and Loss of Vision. Record in detail what health education has been done.

7. Review date

In most cases the worker should return in 12 months for a follow-up assessment however if the worker has been referred for further testing the follow-up date will be as soon as the worker has feedback or the results from the follow up are available.  

8. Storage and Signature

Both the worker and the technician who performed the assessment must sign the vision screening report. If the worker requires a copy of the result for submission for a PrDP / PDP record this in the file and give a copy to the worker. All records are stored for 40 years.

9. Create the legend

Look at the results that have been captured and check for all the abbreviations used including symbols.
Create a legend anywhere on the report and list all the abbreviations and symbols.
Write out what each one means.
This is done so that whoever reads the report will understand what the findings were.

Table 9.2 Example of a Legend

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