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REASON FOR VISIT
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P/C
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Med Hx
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Surg Hx
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Meds
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Allergies
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GLASSES & REFRACTION
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LAST MR OD
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LAST MR OS
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LAST MR ADD OU
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AR OD
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AR OS
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AR ADD OU
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MR OD
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MR OS
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MR ADD OU
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VA
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SC OD 20/
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SC OS 20/
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CC OD 20/
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CC OS 20/
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PH OD 20/
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PH OS 20/
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BAT LO OD 20/
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BAT LO OS 20/
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Ta OD 20/
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Ta OS 20/
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TROPICAMIDE/PHENY/CYCLO/PROPARACAINE Dilation and Anesthetic Warning DISCUSSED
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OU OD OS
• • •
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TIME
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MENTAL STATUS
• • •
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Amstergrid
• • •
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New Free Draw
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OU
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90 D OD
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90 D OS
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BIO OD
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BIO OS
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Vit OD
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Vit OS
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Disc OD
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Disc OS
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BV OD
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BV OS
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Retina Flat OU OD
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Retina Flat OU OS
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Macula FR+OU OD
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Macula FR+OU OS
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Pupils ERR
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Pupils ERR
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Visual Fields Full to Confrontation
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Visual Fields Full to Confrontation
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Motility EOMF
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Motility EOMF
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New Free Draw
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SLE
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Lids OD
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Lids OS
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CONJ W/Q OD
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CONJ W/Q OS
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Tear F OD
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Tear F OS
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TUBUT OD: ___ sec
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TUBUT OD: ___ sec
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TMen OD: ____ mm
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TMen OS: ____ mm
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SPK OD
• • •
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SPK OS
• • •
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ZQ OD
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ZQ OS
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Cornea Clear OU OD
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Cornea Clear OU OS
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A/C D/Q OU OD
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A/C D/Q OU OS
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Lens Clear OU OD
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Lens Clear OU OS
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NS OD
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NS OS
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PSC OD
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PSC OS
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Cortical OD
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Cortical OS
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RTC
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Assessment and PlanNew Short Text Field
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DFE VF OCT: MAC / RNFL FUNDUS PHOTO ARX IOP CHECK BSCAN AVASTIN OD OS OU
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DRY EYE SYNDROME / BLEPHARITIS SYMPTOMATIC
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CATARACT OD OS: VISUALLY SIGNIFICANT ADL / DRIVING / GLARE SX DISCUSSED
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GLAUCOMA SUSPECT / POAG / OMT PT EDUCATED; TREATMENT DtSCUSSED
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DIABETIC RETINOPATHY OD OS: NPDR / PDR / CSME TREATMENT OPTIONS DISCUSSED
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MACUALR DEGENERATION OD OS; DRY / EXUDATES VISUAL DISTORTION
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Comments
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RISK, BENEFITS AND ALTERNATIVES DISCUSSED
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DIAGNOSIS DISCUSSED; PT EDUCATED
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RESTRICTIONS / POST OP CARE INSTRUCTIONS GiVEN
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RD PRECAUTlONS DISCUSSED; RETURN TO CLINIC ASAP
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WARM COMPRESSES / LID SCRUBS / ARTIFICAL TEARS
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VITAMINS SUPPLEMENTS; AREDS / OCUVlTE
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NO DRIVING UNTIL VISION RETURNS TO NORMAL
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IMPORTANCE OF GOOD CONTROL OF DM; HTN; CHOL D/W PT
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