AI scribe and clinic software for optometry and independent eye care practices

The eye examination record, finding by finding

The College of Optometrists asks optometrists to record all clinical findings, legibly and at the time of the examination or as soon as possible afterwards, with a history covering the reason for the visit, symptoms, medicines, family history, visual needs and whether the patient drives.¹ wai drafts the record in that order from the spoken examination. An ambient scribe records what is said, so refraction, pressures and fields reach the draft when the optometrist reads them aloud, and the instrument printouts stay the source for every figure.

Referral thresholds are specific. Before referral for suspected chronic open angle glaucoma, NICE asks for a visual field assessment, optic nerve assessment by stereoscopic slit lamp biomicroscopy, OCT or an optic nerve head image, Goldmann-type applanation tonometry and an assessment of the anterior chamber angle, and says not to refer on non-contact tonometry alone.² It recommends referral for optic nerve head damage, a visual field defect consistent with glaucoma, or a pressure of 24 mmHg or more on Goldmann-type applanation, after considering a repeat measurement.² A template field for each test keeps the referral complete.

wai suggests ICD-10 and SNOMED CT codes from the record, each beside the line of the examination it rests on, for the optometrist to confirm. Typical WHO ICD-10 codes in optometry are H52.1 for myopia, H52.4 for presbyopia, H40.0 for glaucoma suspect, H40.1 for primary open-angle glaucoma, H25.9 for senile cataract, unspecified, and H35.3 for degeneration of macula and posterior pole. ICD-10-CM in the US words some of these differently, so H25.9 there is unspecified age-related cataract. Procedure codes, CPT in the US, and NHS sight test claims stay with the practice's own process.

Referral letters, GOS forms and letters to the patient

The referral letter is the document that matters most. NICE asks for the results of all examinations and tests to go with a glaucoma referral.² wai drafts the referral to ophthalmology from the same examination, with the reason and urgency, the findings for each eye, the pressures, fields and imaging as recorded, the history and medicines and the question for the ophthalmologist, for the optometrist to check and sign. The ophthalmology page covers the receiving side, and the referral letter sets out what a good referral carries.

In England, NHS sight tests run on General Ophthalmic Services forms, the GOS1 claim for the test and the GOS18 for referral to the GP or the hospital eye service. wai does not complete GOS forms or submit claims. The referral content it drafts copies as plain text, or travels as a signed PDF, into the form or route the practice already uses. NHS-funded sight tests in England cover groups that include children under 16, people aged 60 or over, people with diabetes or glaucoma, and people aged 40 or over whose parent, sibling or child has glaucoma.⁴

Letters to the patient follow the Academy of Medical Royal Colleges' advice that most letters are written to the patient with a copy to the GP.⁵ After a referral, the patient's letter says in plain words what was found, why a specialist should see it and what to do if vision changes suddenly. Driving advice is written down too. In the UK a car driver must read a number plate from 20 metres and have visual acuity of at least 6/12 with both eyes together, or with the one eye if only one has sight, plus an adequate field of vision, and must tell DVLA about any eyesight problem that affects both eyes.³ Bus and lorry drivers meet a stricter standard of at least 6/7.5 in the better eye.³ The draft records what the optometrist advised, against the right standard for the licence.

The eye examination in the patient's own language

wai works in 60 languages, among them English, Arabic, Spanish, French, Portuguese, Italian, Russian, Polish, Turkish, Urdu and Mandarin. English can be mixed in one consultation with Spanish, French, Portuguese, Russian, Italian, Dutch, German, Hindi or Japanese, and the other languages are captured in that language. The signed record is written in English, and the patient's summary can be translated into their language beside it, with crisis and emergency numbers kept exactly as written.

In optometry the history depends on the patient describing symptoms precisely, flashes, floaters, a shadow across the vision, and the advice that follows has to be understood. The translated summary carries the warning signs and the recall date in the patient's language. In a systematic review of 33 studies, 76% found at least one outcome better when patient and physician shared a language other than English.⁷ The multilingual scribe page shows how capture works.

Clinic software for optometry clinics, built around the recall

An independent practice lives on its recall list. Absent clinical indications, the College sets minimum intervals of two years for patients aged 16 and over and one year for a person with diabetes who is not in a retinopathy monitoring scheme, and asks for the reason for any earlier recall to be recorded.¹ wai sends recalls for the routine examination, the pressure recheck or the repeat field test at the interval the optometrist set, each message approved by a person before it goes.

Calls, email, web forms and WhatsApp land in one thread per patient, and wai drafts each reply in the practice's voice for a person to approve, from a question about a broken frame to a message about new floaters, where a person at the desk decides who is seen today. Booking links read each optometrist's calendar in Google, Outlook or Apple, cancellations backfill from the waitlist and reminders go out. Deposits, invoices, memberships such as eye care plans, and payment links run through the practice's own Stripe account.

Before each examination the optometrist sees a sourced brief of the patient, the last prescription, previous pressures and any referral, each fact traced to the visit or letter it came from. After the visit, the signed plan goes home in plain words and each referral is tracked until it is done, so a patient referred for suspected glaucoma who has heard nothing is followed up. The full desk is on the clinic management software page.

One eye examination, start to finish

Take a 58-year-old man who comes for a routine eye examination and mentions that his father had glaucoma. He drives for work and wants new varifocals. The optometrist reads out his acuities, 6/6 in each eye with the new prescription, measures pressures of 25 and 26 mmHg on non-contact tonometry, repeats them on a Goldmann-type tonometer at 24 and 25 mmHg, and describes asymmetric cupping of the optic discs. A field test shows an early defect in the left eye.

The draft fills the examination template, with the family history and driving recorded, the refraction, the pressures by method, the disc findings and the field result. wai suggests H40.0 for glaucoma suspect beside the lines it rests on. The optometrist corrects the pressures, which the draft had swapped between the right and left eye, adds the OCT finding she had not read aloud, confirms the code and signs.

A referral to ophthalmology goes with every test result, as NICE asks, and she attaches the signed letter to the GOS18 the practice already uses. The patient's letter, copied to his GP, explains in plain words why he is being referred and records that his vision meets the car driving standard. At the front desk, the varifocals are invoiced through Stripe, the referral is tracked until the hospital appointment is confirmed and a recall is set for his next examination, each message approved by a person.

The evidence behind wai's method

The note is one part of the day the evidence measures. In a randomised trial of 238 outpatient physicians across 14 specialties at UCLA Health, the ambient scribe with a significant effect cut the time spent writing each note by about 41 seconds, against 18 seconds in usual care.⁶ wai is built on that finding, so it takes on the referral, the patient's letter, the replies and the recalls as well as the record.

Optometry's own guidance is about completeness. The College asks for every finding to be recorded at the time,¹ and NICE asks for every test result to travel with a glaucoma referral.² A template with a field for each test makes a missing result visible before the letter is signed.

A draft stays a draft until a person signs it. The Academy of Medical Royal Colleges says the clinician checks every document a scribe produces.⁵ wai holds every draft until the optometrist signs it, and every reply until a person at the practice sends it.

Measured in a working clinic. At The Wellness in London, which runs on wai every day, every clinician has 15 hours a week back, as published in the customer story.⁸

Where to start

Start with routine examinations for one optometrist. Load the practice's examination template, with fixed fields for each eye, the tonometry method and the field result, and run it for two weeks. Count corrections to laterality and figures, and time the gap from the last patient to signed referrals.

In the second week, add referral letters and switch on recalls. Read AI scribe accuracy for how to audit drafts, see how other specialties run wai on the specialties hub, and find prices on the pricing page.

Frequently asked questions