Refractive Patient Note

[Clinician full name and title] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Professional registration number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Patient Name: [Full patient name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date of Birth: [Date of birth in DD/MM/YYYY format] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medical Record Number: [Medical record number] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date of Consultation: [Consultation date in DD/MM/YYYY format] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Reason for Visit: [Reason for visit including presenting complaint and referral context] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in full sentences as a paragraph.) Background: [Background including duration, severity, nature of symptoms, progression, previous interventions, and treatment response] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in full sentences as a paragraph.) Ocular History: [Previous ocular diagnoses, surgeries, trauma, or treatments for each eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medical History: [Relevant systemic medical conditions, surgeries, and hospitalisations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medications: [Current medications including ocular and systemic therapies with dose and frequency] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Allergies: [Known allergies and type of reaction] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Ophthalmic Examination: Visual Acuity: [Visual acuity measurements for each eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Use bullet points.) Refraction: [Right eye refraction values] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Left eye refraction values] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Intraocular Pressure: [Intraocular pressure measurements for each eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Use bullet points.) Examination: [Findings for lids, lashes, conjunctiva, sclera, cornea, anterior chamber, iris, lens, optic nerve, macula, and retina for each eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Summary: [Working diagnosis or clinical impressions for each eye] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in full sentences as a paragraph.) Recommendation: [Treatment plan and medications prescribed or continued] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Use bullet points.) Risks: [Risks discussed with the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Clinician full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Clinician role or position] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [Clinic or service name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)