The pupillary examination, often called the PERRLA assessment, is a quick, non-invasive method used by healthcare professionals to evaluate neurological function. PERRLA is a mnemonic device for documentation, standing for Pupils Equal, Round, Reactive to Light, and Accommodation. The assessment provides a rapid baseline of the function of Cranial Nerves II (Optic) and III (Oculomotor), which control sight and pupil movement. Accurate documentation of these findings is paramount for monitoring a patient’s neurological status and identifying subtle changes that may indicate a developing health issue. This guidance focuses on the precise language required for accurate charting of this assessment in a clinical setting.
Essential Steps of the PERRLA Assessment
The physical assessment follows a sequential pattern to ensure all components are observed accurately. The clinician first inspects the eyes to determine the size and shape of the pupils in ambient light. A millimeter ruler or pupillary gauge is used to measure the resting diameter of each pupil, establishing a baseline measurement. Pupils should appear round and equal in size, though a slight difference is normal for some people.
Next, reactivity to light is assessed by checking both the direct and consensual light reflexes. The direct reflex is the constriction of the pupil when light is shone directly into that eye. The consensual reflex is the simultaneous constriction of the opposite pupil, indicating healthy neurological pathways. This process is typically performed in a dimly lit room to maximize the observed reaction.
Finally, the accommodation reflex is assessed by having the patient shift their gaze from a distant object to a near object, such as the clinician’s finger. When focusing on the near object, healthy pupils constrict and the eyes converge inward. This systematic approach ensures all components of the pupillary response are evaluated.
Charting Standard (Normal) Findings
When all components of the assessment are within expected limits, the standardized acronym PERRLA is used for documentation efficiency. This abbreviation confirms that the pupils are equal, round, reactive to light, and reactive to accommodation.
For clarity, the actual size of the pupils should be included alongside the acronym, documented in millimeters (mm). For example, a complete normal entry might read, “Pupils 4mm bilaterally, PERRLA.” This provides a measurable baseline against which future assessments can be compared. If the accommodation reflex is not tested or is not relevant to the patient’s current care setting, the documentation may use the shortened form, “PERRL,” which omits the accommodation component.
Documenting Abnormal Findings and Deviations
When the assessment reveals a deviation from the norm, the full descriptive language must be used instead of the PERRLA acronym. Specific numerical and descriptive details replace the abbreviation to ensure clarity. For instance, if the pupils are unequal (anisocoria), the size of each pupil must be documented separately in millimeters, such as “Right pupil 5mm, Left pupil 3mm.”
Reactivity to light requires descriptive adjectives like “brisk,” “sluggish,” or “fixed” (non-reactive). A fixed pupil, which fails to constrict, is a significant finding that must be explicitly charted. The entry should specify the affected eye and the nature of the deficit, such as “Right pupil fixed, dilated to 7mm; Left pupil briskly reactive at 4mm.”
Irregular pupil shapes, such as oval or jagged pupils, should also be noted, as this can indicate prior injury or surgery. If one pupil shows a delayed or reduced response compared to the other, a Relative Afferent Pupillary Defect (RAPD) may be present. This is often documented as a “sluggish” or “poor” reaction on the affected side. Precise documentation of all irregularities is required for accurate monitoring of neurological status.
Documentation Standards in Clinical Practice
Accurate documentation of the pupillary exam must adhere to professional standards for medical record-keeping. The record must be created contemporaneously, meaning findings should be charted immediately after the assessment. This timeliness ensures the entry reflects the patient’s current neurological status, which is important as pupil changes can evolve rapidly.
All entries require clarity and legibility, whether charting is electronic or paper-based. The date, exact time of the assessment, and the signature or initials of the clinician must be included with every entry. The PERRLA assessment is commonly integrated into broader charting frameworks, such as comprehensive neurological checks, admission assessments, and routine shift evaluations.