[patient full name] was seen for [reason for visit] on [date of visit].
Past Ocular Hx: [detailed past ocular history including diagnosis, maximum intraocular pressure, family history, ocular trauma, steroid use history, migraines, previous surgical procedures with dates and effects, and central corneal thickness] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph, following the same flow and abbreviations as the example.)
Chief Complaint (Technician's notes): [detailed description of the patient's chief complaint including onset, specific symptoms, affected eye, inability to focus, previous consultations with optometrists, concerns raised by optometrists, referrals to specialists, findings from specialists, progression noted by doctors, and other relevant ocular history such as bilateral glaucoma, previous surgeries with dates and effects, and bilateral cataracts] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph of full sentences.)
[mention if the patient is on blood thinners, denies history of refractive laser surgery, history of head concussions with dates of last concussion, and if eye drops were administered on the day of visit] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph of full sentences.)
[document any allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph of full sentences.)
Eye Medications:
[list of eye medications including dosage and frequency for each eye] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list, with each medication on a new line.)
" (Report dilligence)"
[mention if the patient used drops this morning and/or last night] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write following a hyphen next to the relevant medication)
Clinical Examination:
Visual Acuity:
OD: [visual acuity measurements of right eye, including pinhole correction if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a new line, following the same format as the example.)
OS: [visual acuity measurements of left eye, including pinhole correction if applicable] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a new line, following the same format as the example.)
Intraocular Pressure: [intraocular pressure measurements for both eyes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a single line, following the same format as the example.)
Anterior Segment: [description of anterior segment findings including injection and periorbital erythema for both eyes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a single line.)
Gonioscopy (Spaeth): [gonioscopy findings for both eyes, including Spaeth grading and presence of PAS] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a single line.)
Lens: [lens findings for both eyes, including degree of nuclear sclerosis] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a single line.)
Optic Nerve:
OD: [description of optic nerve findings for the right eye, including cup-to-disc ratio] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a new line, following the same format as the example.)
OS: [description of optic nerve findings for the left eye, including cup-to-disc ratio and presence of inferior notch] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a new line, following the same format as the example.)
Fundus: [description of fundus findings for both eyes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a single line.)
Visual Fields:
[details of who performed the visual field test and the date of the test] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a new line, within parentheses.)
OD: [visual field findings for the right eye, including remaining visual field and progression status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a new line, following the same format as the example.)
OS: [visual field findings for the left eye, including type of defect and stability status] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a new line, following the same format as the example.)
OCT:
RNFL: [description of retinal nerve fiber layer findings for both eyes, including degree and location of thinning] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a new line, following the same format as the example.)
GCL: [description of ganglion cell layer findings for both eyes, including degree of loss and which eye is more affected] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a new line, following the same format as the example.)
macula: [description of macula findings for both eyes, including atrophy and which eye is more affected] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write on a new line, following the same format as the example.)
Assessment (Doctor's notes):
1. [assessment of glaucoma including affected eyes, progression status, and any associated conditions or reactions such as topical allergies and likely causative drops] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph, following the numbered list format.)
2. [assessment of cataracts including affected eyes, visual significance, and potential benefits of cataract surgery in relation to other procedures] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph, following the numbered list format.)
Plan: [details of the discussion with the patient regarding risks, benefits, and alternatives of proposed procedures, the patient's agreement to proceed, specific procedure details (e.g., type of microshunt, use of mitomycin C, and cataract surgery), the eye involved, placement on waitlist, continuation of current medications, and any changes to medication regimens including name of new medication, dosage, frequency, and reason for change to optimize ocular surface in preparation for surgery] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a single paragraph of full sentences.)
(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.)
