|
HPI
|
|
|
Onset: *
• • •
|
No trauma.
|
|
Course*
• • •
|
Severity*
|
|
Fever?
|
Vision changes
• • •
|
|
Recent URI?
• • •
|
Sick contacts?
• • •
|
|
Additional notes
|
Red eyes?
• • •
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Positive (EYE)
• • •
|
Negative (EYE)
• • •
|
|
Skin (positive)
• • •
|
Skin (negative)
• • •
|
|
Insert Macro Here
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
Location:
• • •
|
|
|
Positive findings (EYE)
• • •
|
Negative findings (EYE)
• • •
|
|
Normal Slit lamp exam (tetracaine and fluorescein used)
|
Normal Wood's lamp (tetracaine and fluorescein used)
|
|
Additional Eye Findings
|
|
|
PE: Superficial
|
PE: Head to toe (abd deferred)
|
|
Insert PE Macro Here
|
|
|
|
|
|
MDM
|
Clinic Visit CPT CODE***
|
|
DDx: conjunctivitis, iritis, corneal abrasion, subconjunctival hemorrhage, stye, blepharitis, allergic conjunctivitis
|
MDM Notes
|
|
Status
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
Referred to Optho for eval and treatment
|
|
Discharge Notes:
|
|
|
Discharge pt home
|
Discharge Note: ERD ONLY
|
