[Date of the consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write the date in full, spelling out the day, month and year.)
Client Details
[Client title and surname] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Client address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on separate lines.)
[Client postcode] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Patient Details
Name: [Pet name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Age: [Pet age in years and/or months] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Sex: [Pet sex and reproductive status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Species: [Pet species] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If the species is dog, write: "Canine".)
Breed: [Pet breed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
<u>History</u>
Condition being monitored: [Condition the patient is being monitored for] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Previous appointment: [Details of what occurred at the previous appointment including any treatment changes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Progress since last appointment: [How the patient has been since the last appointment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
Current medications: [Current medications the patient is receiving] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list.)
(If no information for this section is mentioned in transcript, contextual notes or clinical note, omit the section entirely.)
<u>Ophthalmic Examination</u>
(OD = right eye, OS = left eye, OU = both eyes. Use concise medical terminology throughout this section.)
Distant Examination
Ocular OD: [Distant examination ocular findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Ocular OS: [Distant examination ocular findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Periocular OD: [Distant examination periocular findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Periocular OS: [Distant examination periocular findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Head OD: [Distant examination head findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Head OS: [Distant examination head findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Visual axis OD: [Distant examination visual axis findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Clear tapetal reflex".)
Visual axis OS: [Distant examination visual axis findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Clear tapetal reflex".)
Tear Film Parameters and Intraocular Pressures
STT (mm/min) OD: [STT measurement for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "n.d.".)
STT (mm/min) OS: [STT measurement for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "n.d.".)
Tear film quality OD: [Tear film quality for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Good".)
Tear film quality OS: [Tear film quality for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Good".)
IOP (mmHg) OD: [IOP measurement for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "n.d.".)
IOP (mmHg) OS: [IOP measurement for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "n.d.".)
Neuro-Ophthalmic Examination
PLR OD: [PLR findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
PLR OS: [PLR findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Consensual PLR OD: [Consensual PLR findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "OD>OS: Positive".)
Consensual PLR OS: [Consensual PLR findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "OS>OD: Positive".)
Chromatic PLR blue OD: [Chromatic PLR blue findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Chromatic PLR blue OS: [Chromatic PLR blue findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Chromatic PLR red OD: [Chromatic PLR red findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Chromatic PLR red OS: [Chromatic PLR red findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Menace OD: [Menace response for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Menace OS: [Menace response for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Dazzle OD: [Dazzle reflex for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Dazzle OS: [Dazzle reflex for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Vestibulo-ocular reflex OD: [Vestibulo-ocular reflex findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Vestibulo-ocular reflex OS: [Vestibulo-ocular reflex findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Corneal OD: [Corneal reflex findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Corneal OS: [Corneal reflex findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Palpebral OD: [Palpebral reflex findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Palpebral OS: [Palpebral reflex findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Slit Lamp Examination
Eyelids OD: [Eyelids examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Eyelids OS: [Eyelids examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Lacrimal punctae OD: [Lacrimal punctae examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Lacrimal punctae OS: [Lacrimal punctae examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Palpebral conjunctiva OD: [Palpebral conjunctiva examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Palpebral conjunctiva OS: [Palpebral conjunctiva examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Bulbar conjunctiva OD: [Bulbar conjunctiva examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Bulbar conjunctiva OS: [Bulbar conjunctiva examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Third eyelid OD: [Third eyelid examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Third eyelid OS: [Third eyelid examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Cornea OD: [Cornea examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Cornea OS: [Cornea examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Sclera OD: [Sclera examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Sclera OS: [Sclera examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Anterior chamber OD: [Anterior chamber examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Anterior chamber OS: [Anterior chamber examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Iris OD: [Iris examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Iris OS: [Iris examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Iridocorneal angle OD: [Iridocorneal angle examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Iridocorneal angle OS: [Iridocorneal angle examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Lens OD: [Lens examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Lens OS: [Lens examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Vitreous OD: [Vitreous examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Vitreous OS: [Vitreous examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Retina/optic nerve OD: [Retina and optic nerve examination findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Retina/optic nerve OS: [Retina and optic nerve examination findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD".)
Additional Ophthalmic Diagnostics
(If no information for this section is mentioned in transcript, contextual notes or clinical note, omit the section entirely.)
Fluorescein test OD: [Fluorescein test findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Negative".)
Fluorescein test OS: [Fluorescein test findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Negative".)
Jones test OD: [Jones test findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Jones test OS: [Jones test findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "Positive".)
Ultrasound OD: [Ultrasound findings for the right eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Ultrasound OS: [Ultrasound findings for the left eye] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
<u>Clinical Photographs</u>
(If no clinical photographs were taken as mentioned in transcript, contextual notes or clinical note, print: "Not taken" and omit the placeholders below.)
Right eye: [Image reference or description of the right eye clinical photograph] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Left eye: [Image reference or description of the left eye clinical photograph] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Right fundus: [Image reference or description of the right fundus photograph] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Left fundus: [Image reference or description of the left fundus photograph] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Profile: [Image reference or description of the profile photograph] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
<u>Diagnosis</u>
[Document the clinician's explicitly stated diagnoses, differential diagnoses or problem list] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write in paragraphs of full sentences.)
<u>Recommended Treatment</u>
[Recommended treatments, diagnostic plan or therapeutic plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If medications are mentioned, list them as a written list. Other recommendations should be written in paragraphs of full sentences.)
<u>Summary</u>
[Clinical summary of findings, diagnostic reasoning, treatment plan and any prognostic considerations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
<u>Next Follow-Up Examination</u>
[Recommended timeframe or date for the next follow-up examination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
"Thank you for referring this case, it was a pleasure looking after [Pet name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.). Please feel free to contact me by phone or email in case of any questions. Our contact telephone number is [Practice telephone number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.), alternatively you can email [Practice email address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)."
[Referring clinician full name and qualifications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Referring clinician professional titles or accreditations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Referring clinician role and training status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
Supervised by:
[Supervisor full name and qualifications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Supervisor professional titles or accreditations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
[Supervisor role or position] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely.)
(Never come up with your own pet 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 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. When writing timelines, always spell out the units, e.g., "weeks", "months", "days", and do not use fractional notation like /52, /12, or /7. Always use abbreviations for medication frequencies, e.g. SID, BID, TID, QID, and for eyes, e.g. OS, OD, OU.)
