Checklist template

Eye exam lane readiness and patient flow for optical stores

A ready-to-use checklist with 105 items in 6 sections, covering Pre-test, Exam room, Equipment, Disinfection, Hand-off to dispensing, Wait times. Use it as-is in Bindy, or adapt it to your own standards in minutes.

  • 6 Sections
  • 105 Items
  • 85 Yes / No checks
  • 6 Scored ratings
  • 115 Points

Use this template How audits work

1. Pre-test 17 items

  1. Patients are checked in at reception on arrival and marked as arrived in the schedule Yes / No 1 pt
  2. The patient's identity is confirmed with name and date of birth before pre-testing starts Yes / No 1 pt
  3. The history questionnaire (medications, allergies, eye and family history) is completed before pre-testing Yes / No 1 pt
  4. The patient's current glasses are read on the lensmeter and the reading is entered in the record Yes / No 1 pt
  5. For contact lens wearers, the brand and parameters of the current lenses are entered in the record Yes / No 1 pt
  6. Autorefractor and keratometer readings are transferred or attached to the record Yes / No 1 pt
  7. Non-contact tonometer readings are recorded for each eye with the time taken Yes / No 1 pt
  8. Visual field screening is run when the company protocol calls for it Yes / No 1 pt
  9. The fee for optional retinal imaging is explained before the image is taken Yes / No 1 pt
  10. The technician tells the patient what each instrument does before the test starts Yes / No 1 pt
  11. Pre-test instruments are arranged so the patient moves from one to the next without crossing the waiting area Yes / No 1 pt
  12. The instrument table height is adjusted for each patient Yes / No 1 pt
  13. At least one pre-test station can be reached by a patient in a wheelchair Yes / No 1 pt
  14. Pre-test results are in the record before the doctor enters the exam room Yes / No 1 pt
  15. A training record exists for each technician on each pre-test instrument used Yes / No 1 pt
  16. Minutes taken by one pre-test sequence observed Number
  17. Pre-test sequence observed Rating
    • Complete, explained and recorded 5 pts
    • Complete but not explained or partly recorded 3 pts
    • Tests skipped or results missing 1 pt

2. Exam room 20 items

  1. Each exam lane is stocked at opening from a written checklist Yes / No 1 pt
  2. The exam chair raises, lowers and reclines Yes / No 1 pt
  3. The chair upholstery is free of tears Yes / No 1 pt
  4. The phoropter arm swings into place and locks in position Yes / No 1 pt
  5. The acuity chart displays every line and optotype without dead pixels or burned-out sections Yes / No 1 pt
  6. The acuity chart is calibrated for the test distance of the room Yes / No 1 pt
  7. The room lights dim from the doctor's position Yes / No 1 pt
  8. A near point card and an occluder are in the lane Yes / No 1 pt
  9. The trial lens set is complete, with no empty slots Yes / No 1 pt
  10. Fluorescein strips, tissues and cotton-tipped applicators are stocked Yes / No 1 pt
  11. Diagnostic drops are in date Yes / No 1 pt
  12. Opened multi-dose drop bottles carry the date opened Yes / No 1 pt
  13. Diagnostic drops are locked away when the lane is unattended Yes / No 1 pt
  14. The exam room computer is locked when the room is unattended Yes / No 1 pt
  15. The screen cannot be read from the corridor or the waiting area Yes / No 1 pt
  16. No patient record or prescription from an earlier patient is left in the lane Yes / No 1 pt
  17. The lane door closes fully for privacy during the exam Yes / No 1 pt
  18. The floor between the door and the exam chair is free of cords and stools Yes / No 1 pt
  19. Exam lanes in use on the day of the visit Number
  20. Readiness of the exam lanes inspected Rating
    • Every lane stocked and working 5 pts
    • One lane with missing supplies or a fault 3 pts
    • Several lanes not ready 1 pt

3. Equipment 20 items

  1. The slit lamp illuminates at all brightness settings Yes / No 1 pt
  2. The slit lamp joystick moves smoothly in every direction Yes / No 1 pt
  3. The slit lamp base locks in position Yes / No 1 pt
  4. The applanation tonometer has had its calibration check with the weight bar on the company schedule Yes / No 1 pt
  5. Date of the last applanation tonometer calibration check Date
  6. The autorefractor has been checked against its model eye on the manufacturer's schedule Yes / No 1 pt
  7. The lensmeter used for pre-testing reads zero with no lens in place Yes / No 1 pt
  8. Phoropter lenses are free of fingerprints and haze when viewed through each aperture Yes / No 1 pt
  9. The binocular indirect ophthalmoscope is charged Yes / No 1 pt
  10. Condensing lenses are stored in their cases, free of scratches Yes / No 1 pt
  11. The retinal camera or OCT captures a test image and saves it to the record system Yes / No 1 pt
  12. The visual field analyzer exports or prints its results Yes / No 1 pt
  13. The retinoscope and direct ophthalmoscope are charged Yes / No 1 pt
  14. A spare bulb or a spare handle for the retinoscope and ophthalmoscope is on site Yes / No 1 pt
  15. Dust covers are placed on instruments at closing Yes / No 1 pt
  16. Each instrument carries a preventive maintenance label that is in date Yes / No 1 pt
  17. An out-of-service instrument is tagged and has been reported to the service provider Yes / No 1 pt
  18. A written plan states how patients are handled when the autorefractor or tonometer is down Yes / No 1 pt
  19. Instruments out of service at the time of the visit Number
  20. Condition of exam and pre-test equipment Rating
    • All working and maintained 5 pts
    • Minor faults reported and being handled 3 pts
    • Faults unreported or exams affected 1 pt

4. Disinfection 13 items

  1. Chin rests and forehead rests of pre-test instruments are wiped after each patient, as observed Yes / No 1 pt
  2. Chin rest papers, where used, are torn off after each patient Yes / No 1 pt
  3. The phoropter forehead rest and face shields are wiped before the next patient is seated Yes / No 1 pt
  4. The occluder and near point card are wiped after each patient Yes / No 1 pt
  5. The exam chair armrests are wiped during lane turnover Yes / No 1 pt
  6. Tablets, pens and clipboards handed to patients are wiped after each use Yes / No 1 pt
  7. A container of disinfectant wipes is within reach in each lane Yes / No 1 pt
  8. A container of disinfectant wipes is within reach at the pre-test station Yes / No 1 pt
  9. Wipe containers are closed and the wipes are moist Yes / No 1 pt
  10. Hand rub is mounted at the entrance of each exam lane Yes / No 1 pt
  11. Lane turnover is finished before the next patient is brought in Yes / No 1 pt
  12. Waste bins in the lanes are emptied before they are full Yes / No 1 pt
  13. Turnover cleaning between two patients observed Rating
    • All patient-contact surfaces wiped 5 pts
    • Some surfaces missed 3 pts
    • No cleaning between patients 1 pt

5. Hand-off to dispensing 17 items

  1. The doctor walks the patient to the dispensary or calls an optician into the lane Yes / No 1 pt
  2. The doctor states the lens recommendations to the optician in front of the patient Yes / No 1 pt
  3. The optician has the new prescription in hand or on screen at the hand-off Yes / No 1 pt
  4. The patient is given a copy of the eyeglass prescription at the end of the exam without having to ask, as required by local regulation Yes / No 1 pt
  5. Release of the prescription is not tied to a purchase Yes / No 1 pt
  6. The optician is introduced to the patient by name Yes / No 1 pt
  7. Dilated patients are offered disposable sun shields Yes / No 1 pt
  8. Dilated patients are told how long blur and light sensitivity will last Yes / No 1 pt
  9. Contact lens patients are handed to the contact lens technician with the trial parameters written down Yes / No 1 pt
  10. Exam fees are collected or billed to the plan before the patient leaves Yes / No 1 pt
  11. The next exam or follow-up is booked or a recall is set before the patient leaves Yes / No 1 pt
  12. Referral letters to specialists are sent within the time set by company policy Yes / No 1 pt
  13. A referral log shows the date each referral was sent Yes / No 1 pt
  14. Patients who do not buy are given a written quote Yes / No 1 pt
  15. Patients examined yesterday Number
  16. Patients examined yesterday who ordered eyewear the same day Number
  17. Hand-off from exam to dispensing observed Rating
    • Personal introduction with recommendations stated 5 pts
    • Patient directed to the dispensary without an introduction 3 pts
    • Patient left to find their own way 1 pt

6. Wait times 18 items

  1. Appointment slot lengths in the schedule follow the company template by exam type Yes / No 1 pt
  2. Patients receive an appointment reminder on the company schedule Yes / No 1 pt
  3. The late-arrival policy is applied the same way by each receptionist asked Yes / No 1 pt
  4. Walk-in patients are offered the next open slot or a place on the same-day list Yes / No 1 pt
  5. A cancellation list is used to fill slots that open up Yes / No 1 pt
  6. Breaks for the doctor and the technicians are blocked in the schedule Yes / No 1 pt
  7. The doctor was ready in the lane for the first appointment of the day Yes / No 1 pt
  8. Patients are told of any delay longer than 10 minutes Yes / No 1 pt
  9. The waiting area has a seat for every patient waiting at the busiest time observed Yes / No 1 pt
  10. Minutes from arrival to the start of pre-testing for one patient timed Number
  11. Minutes from the end of pre-testing to the doctor entering the lane for the same patient Number
  12. Total minutes from arrival to hand-off to the dispensary for the same patient Number
  13. No-show appointments yesterday Number
  14. Unfilled exam slots today Number
  15. Days until the next available routine exam appointment Number
  16. Name of the store or clinic manager Short text
  17. Overall patient flow Rating
    • Smooth, on time 5 pts
    • Some delays, patients informed 3 pts
    • Long waits or patients not informed 1 pt
  18. Corrective actions required Comments

About this template

This checklist is part of the Bindy template library. Yes / No checks score 1 point when met; ratings score the points shown for each option. The overall score is the percentage of points earned, with N/A answers excluded. In Bindy you can add photos, assign corrective actions, require sign-off and compare results across sites.

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