“Normal/at-baseline” means functional vision is at the patient’s baseline, the external eye is unremarkable, and any chronic deficit is unchanged. Each line states the finding, the comparison to baseline, and the skilled reason a nurse was required — a bare “vision okay” does not qualify.
Functional vision at the patient’s baseline — able to read labels and navigate the home with usual correction, without new change.
No new blurring, double vision, floaters, flashes, curtain, pain, or loss.
External eye without redness, discharge, swelling, or lesion.
Pupils grossly equal and reactive to light, unchanged from baseline.
Eye-drop or ointment technique correct on observation, with appropriate hygiene.
Diabetic or hypertensive retinopathy surveillance current or scheduled, with the last exam date documented.
A chronic stable visual deficit unchanged, with effective low-vision adaptations and the plan appropriate to continue.
