Retinal Surgeon Template

Retinal Surgeon Note

A professional Retinal Surgeon template for healthcare professionals.

About this template

Looking for a streamlined way to document your retinal examinations? This Retinal Surgeon Note template is designed specifically for retinal surgeons. It provides a clear and concise structure for recording key findings, including anterior and posterior segment assessments, OCT results, and a detailed plan. This template helps you efficiently capture all essential information, from patient-reported symptoms to diagnoses and follow-up plans. With Heidi, this template can be quickly populated from your consultation transcript, saving you valuable time and ensuring comprehensive documentation for each patient visit.

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68F presenting for routine retinal review Enjoys gardening and recently celebrated her wedding anniversary. Patient-reported symptoms and/or progress: * Reports mild blurriness in her left eye, especially in the mornings. * No new floaters or flashes. **O/E** **Right eye** **Anterior Seg:** Conj: clear, K: clear, AC: deep and quiet, lens: clear **Posterior Seg:** Vit: clear, Mac: attached, Vessels: healthy, Periphery: stable, Disc: healthy **OCT Mac:** No macular oedema or significant changes since last review. **OCT Disc/RNFL:** Stable RNFL thickness. **Left eye** **Anterior Seg:** Conj: clear, K: clear, AC: deep and quiet, lens: clear **Posterior Seg:** Vit: clear, Mac: attached, Vessels: healthy, Periphery: stable, Disc: healthy **OCT Mac:** Early signs of macular drusen. **OCT Disc/RNFL:** Stable RNFL thickness. **Impression** - Right eye: Stable age-related macular changes. - Left eye: Early macular drusen. - No other significant ophthalmic issues. **Plan** - Continue with current AREDS2 vitamin regimen. - Review in 6 months. - Advised patient to monitor vision changes and report any new symptoms. - Safety-netting: Instructed patient to seek immediate review if experiencing sudden vision loss or distortion.

[Age] [Sex in M or F] presenting for [purpose of ophthalmology review] [Insert short, memorable personal tidbit about the patient – such as recent holiday, occupation, or favourite sports team] [Patient-reported symptoms and/or progress] (Only include if explicitly mentioned in transcript, context or clinical note. Write as short bullet points.) **O/E** **Right eye** **Anterior Seg:** [Conj: , K: , AC: , lens: ] (Only include structures explicitly mentioned in transcript or clinical note. One line only.) **Posterior Seg:** [Vit: , Mac: , Vessels: , Periphery: , Disc: ] (Only include structures explicitly mentioned in transcript or clinical note. One line only.) **OCT Mac:** [Diagnosis or OCT findings in one line] (Only include if explicitly mentioned in transcript or clinical note.) **OCT Disc/RNFL:** [Disc/RNFL findings in one line] (Only include if explicitly mentioned in transcript or clinical note.) **Left eye** **Anterior Seg:** [Conj: , K: , AC: , lens: ] (Only include structures explicitly mentioned in transcript or clinical note. One line only.) **Posterior Seg:** [Vit: , Mac: , Vessels: , Periphery: , Disc: ] (Only include structures explicitly mentioned in transcript or clinical note. One line only.) **OCT Mac:** [Diagnosis or OCT findings in one line] (Only include if explicitly mentioned in transcript or clinical note.) **OCT Disc/RNFL:** [Disc/RNFL findings in one line] (Only include if explicitly mentioned in transcript or clinical note.) **Impression** - [Right eye diagnosis or summary of condition] (Only include if explicitly mentioned in transcript or clinical note.) - [Left eye diagnosis or summary of condition] (Only include if explicitly mentioned in transcript or clinical note.) - [Any additional relevant ophthalmic diagnoses or issues] (Only include if explicitly mentioned in transcript or clinical note.) **Plan** - [Planned or ongoing treatment including injections, surgery, laser, medications, or referrals] (Only include if explicitly mentioned in transcript or clinical note.) - [Next review timeline or follow-up actions] (Only include if explicitly mentioned in transcript or clinical note.) - [Any advice or instructions given to patient] (Only include if explicitly mentioned in transcript or clinical note.) - [Any safety-netting or additional guidance] (Only include if explicitly mentioned in transcript or clinical note.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)

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