A&P Referral for peds exam - children's hospital

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Edu parent that full ocular examination (examining anterior and posterior segment) was not able to be performed today d/t poor patient cooperation. Refer pt to Children's Health Pediatric Ophthalmologist for further evaluation & to assess comprehensive ocular health.  Provided pt with clinic name & contact information. Edu parent to schedule apt with them asap. Edu parent on importance of following up with Children's to ensure ocular health is WNL.

Unreliable spectacle rx findings today d/t poor pt cooperation (did not finalize today's manifest rx). Edu pt to follow up with Children's Health pediatric OMD for further evaluation.


For other places (not Children's):

Refer to pediatric ophthalmologist for second opinion to determine if pt has amblyopia. Poor pt cooperation with obtaining BCVAs - likely reduction in VAs are due to poor pt cooperation rather than amblyopia, but follow up with specialist to confirm. 

Unable to view anterior & posterior segment due to poor patient cooperation. Sent referral to Pediatric Ophthalmologist __________ for an amblyopia & retinal evaluation. Faxed pt records to the clinic. Edu pt/parent/guardian on importance of obtaining referral to ensure ocular health is WNL since unable to view today in office. Edu pt/parent/guardian that sight threatening conditions could be missed if unable to view posterior segment & explained the importance of following up. Pt/parent/guardian understood all instructions. 



To put at the top of the exam summary:

Doctor's Note: Patient currently does not need glasses at this time, but there was poor patient cooperation today, so spectacle prescription & ocular health findings from today are unreliable. Please follow up with Children's Health ophthalmologist for further evaluation - provided parent with contact information to schedule appointment with Children's Health.

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