GRADED
TRIAL
# 1
GRADED
TRIAL
# 2
NOTES
1. ✦ Perform hand hygiene.
2. ✦ Review physician’s order.
3. ✦ Assemble equipment.
4. ✶ Identify the patient and
introduce yourself.
5. ✶ Explain the procedure.
6. ✦ In a well-lit room, have the patient
hold the Jaeger card at a distance
of 14 to 16 inches.
7. ✦ Ask the patient to read aloud,
with both eyes open, the smallest
paragraph or line possible without
error (Figure A).
8. ✶ Document the results accurately,
noting any unusual symptoms,
such as squinting.
GRADING
Points Earned
Points Possible 57 57
Percent Grade (Points Earned/
Points Possible)
PASS: ❑ YES
❑ NO
❑ N/A
❑ YES
❑ NO
❑ N/A
Instructor Sign-O
Instructor: ______________________________________________ Date: _________________________
POINT VALUE
✦ = 3–6 points
✶ = 7–9 points
Name: ________________________________________
Date: _________________________________________
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