Ophthalmologist's note (custom)

History: Chief Complaint: [reason for visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) History of Present Illness: [onset, duration, severity, character of visual complaint] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Past Ocular History: [history of eye diseases, surgeries, treatments, and outcomes] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Medical History: [relevant systemic conditions affecting ocular health] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Medication History: [current ocular and systemic medications] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Allergies: [medication and substance allergies] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Family Ocular History: [eye diseases in family] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Social History: [tobacco, alcohol use, occupational hazards] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Examination: Visual Acuity: [unaided, aided, with pinhole for OD/OS] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Intraocular Pressure: [method and values OD/OS] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Anterior Segment: [slit-lamp examination findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in short bullet points.) Posterior Segment: [dilated fundus examination findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in short bullet points.) Additional Tests / Scans: [results from visual fields, OCT macula, OCT optic nerve fibre layer, corneal tomography, anterior segment OCT] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Assessment: [diagnosis with ICD-10 code if stated] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) [differential diagnoses if considered] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Plan: Treatments: [medications, laser, or surgical interventions planned] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Follow-Up: [interval until next visit and conditions for earlier review] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in full sentences.) Patient Education: [information given about diagnosis, treatment, prognosis] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) Referrals: [referrals to other specialists if required] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) (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 include 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.)