Ophthalmologist Template

Refractive Patient Note

A professional Ophthalmologist template for healthcare professionals.

About this template

Streamline your ophthalmology practice with Heidi's Refractive Patient Note template, meticulously designed for eye care professionals. This comprehensive template captures all essential details for patients considering or undergoing refractive procedures, from initial consultation to examination findings. Ophthalmologists, optometrists, and ophthalmic surgeons will find this 'clinical notes template' invaluable for documenting patient history, visual acuity, refraction, intraocular pressure, and detailed ocular examination results. Heidi intuitively fills in relevant data from your consultations, ensuring accurate and thorough documentation of medical history, current medications, allergies, and proposed treatment plans. Enhance your record-keeping efficiency and focus more on patient care with this specialised eye exam documentation solution.

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Dr. Eleanor Vance, Consultant Ophthalmologist Professional registration number: 1234567 Patient Name: Sarah Jenkins Date of Birth: 15/05/1988 Medical Record Number: SJ88155 Date of Consultation: 01/11/2024 Reason for Visit: Ms. Jenkins presented with a primary complaint of progressively worsening blurry vision in both eyes, more pronounced at night and when reading. She was referred by her GP, Dr. Alex Smith, for evaluation of potential refractive error and suitability for refractive surgery. Background: Ms. Jenkins reports a 6-month history of declining visual clarity. Initially, she noticed difficulty reading small print and signs at a distance. Over the past 3 months, these symptoms have intensified, leading to headaches and eye strain, particularly after prolonged screen use. She has not tried any previous interventions or treatments for this specific issue, beyond over-the-counter reading glasses which provide minimal relief. Ocular History: No previous ocular diagnoses, surgeries, trauma, or treatments reported for either eye. Medical History: Ms. Jenkins has a history of seasonal allergies well-controlled with over-the-counter antihistamines. No other relevant systemic medical conditions, surgeries, or hospitalisations. Medications: * Loratadine 10mg, once daily (as needed for allergies) * Multivitamin, once daily Allergies: * Penicillin (rash) * Codeine (nausea) Ophthalmic Examination: Visual Acuity: * Right Eye (OD): Uncorrected Visual Acuity (UCVA) 6/24, Best Corrected Visual Acuity (BCVA) 6/6 with -2.50 sphere * Left Eye (OS): UCVA 6/30, BCVA 6/6 with -3.00 sphere Refraction: Right eye refraction values: -2.50 / -0.25 x 180 Left eye refraction values: -3.00 / -0.50 x 5 Intraocular Pressure: * Right Eye (OD): 16 mmHg (Goldmann Applanation Tonometry) * Left Eye (OS): 15 mmHg (Goldmann Applanation Tonometry) Examination: Lids and lashes: Clear, no abnormalities. Conjunctiva: White and quiet. Sclera: White. Cornea: Clear, no opacities or oedema. Anterior chamber: Deep and clear. Iris: Normal configuration, reactive pupils. Lens: Clear, no cataracts. Optic nerve: Pink, sharp margins, cup-to-disc ratio 0.3 in both eyes. Macula: Flat, no drusen or oedema. Retina: Attached, no tears or detachments observed in periphery for both eyes. Summary: Ms. Jenkins presents with symptomatic myopia and mild astigmatism in both eyes, consistent with her refractive error measurements. There are no other ocular pathologies identified. She is a suitable candidate for further discussion regarding refractive surgery options given her desire for reduced spectacle dependence. Recommendation: * Discuss potential for laser refractive surgery (e.g., LASIK or PRK) as a long-term solution for myopia and astigmatism. * Provide information on benefits, risks, and post-operative care. * Schedule a follow-up appointment for further detailed counselling and pre-operative assessments, including corneal topography and pachymetry. * Continue current medications as prescribed. Risks: Potential risks of refractive surgery, including dry eyes, glare, halos, under- or over-correction, infection, and vision loss (rare), were discussed with the patient. The importance of understanding these risks and making an informed decision was emphasised. Dr. Eleanor Vance Consultant Ophthalmologist City Eye Clinic

[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.)

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