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Departments & Programs,UW Health,Ambulatory Education,Ambulatory Orientation,Checklists - Core and Department Specific,Resources


Ophthalmology - Departments & Programs, UW Health, Ambulatory Education, Ambulatory Orientation, Checklists - Core and Department Specific, Resources

OPHTHALMOLOGY - CLINICAL TRAINING CHECKLIST ----- This is due three months from hire date------

Employee Name: __________________________________ Employee Credentials:________ Hire Date: ____________

Clinic Location/ number: _______________________ Employee Number ________________________

*Refer to appropriate UWMF policy= *** N/A on checklist indicates that it is not indicated for the employee***
***Each area should either be discussed or observed by preceptor***

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Employee is able to gather data relevant to the following:
Assess and record visual acuities
History, medical care of eye
Neutralizing glasses with Lensometer- (Auto and Manual)
Assess Pupils
Refraction (Autorefractor and Phoropter)
Ophthalmic Photography
Visual Fields/Goldmann & Humphrey
Stereopsis testing
Blood Pressure Measurement *
Tonometry (Tono-pen, Golmann Applanation, NCT)
Color Vision Testing
Amsler Grid
Confrontation Visual Fields
Assessing Anterior Chamber Depth and Pupil Dilation
Ophthalmic Pharmacology
Orbscans, Wavescans
Measuring Tear Production
Diabetic Information (Blood sugars levels)

Diagnostic/tests- Demonstrate competence to assist/set-up/patient

Visual fields Goldmann and Humphrey
Ophthalmic Ultrasound (A Scan, B Scan, & IOL Master)

AREA OF ORIENTATION Discussed Observed Preceptor’s Signature Completed date
Administration of Medications
Eye Drops, Ointments, Eye Patch *
Maintain Sample drug supplies, DEA Procedures/Controlled Substances Log *
Properly documents administered medications
Properly disposes of expired medications & unused or discarded or refused
medications *

Schedule and Preauthorizations, Pre-op Testing
Surgical agreements and Pre-Op packets
Labs, Chest X-rays, EKG

Ophthalmology Policies
Eye Drop Administration
Triage Protocol
Tonometer Tip Cleaning
Contact Lens Refill and Replacement

I, _________________________________________ (employee name) have completed the Core Competency Checklist and attest the information
is true and valid. I have demonstrated or discussed these skills and I am responsible for performing patient care as a Certified Medical Assistant /
Licensed Practical Nurse / Registered Nurse (circle one).

__________________________________________________ ___________________ Additional Preceptor Signatures/initials:
Preceptor Date
____________________________________________________ ___________________
Supervisor Date 2._______________________________

__________________________________________________ ___________________ 3._______________________________
Provider Date

Initially Competed 12-12-02;Revised 5-8-03, 8/07, 9/2011, 3/2012, 3/2017

 Send the original signed Core Competency Checklist to Clinical Staff Education – 1035.
 One copy of the signed Core Competency Checklist should be placed in the clinic’s staff employee’s file, and a copy given to the employee.

Brener, T., Doyle, R.M. (Ed.). (2008). Nursing 2008 drug handbook. Philadelphia, PA: Lippincott Williams & Wilkins.
Perry, A.G. & Potter, P.A. (2002). Clinical nursing skills & techniques. (5th ed.). St. Louis, MO: Mosby.
Perry, A.G. & Potter, P.A. (2009). Fundamentals of nursing. (7th ed.). Hall, A. & Stockert, P.A. (Eds.). St. Louis, MO: Mosby Elsevier.