Bright Eyes A&P Templates
OV: Edu pt on condition & findings. RTC for an evaluation/appointment sooner than scheduled follow up if condition worsens including but not limited to increased ocular redness, discomfort, or reduction in vision occur. Pt understood all instructions. Provided pt with BEVC office number for same day appointment scheduling & number for on-call doctor after hours.
If applicable, parent/guardian was also educated on the above information.
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Edu pt on condition & findings. RTC for an evaluation/appointment sooner than scheduled follow up if condition worsens including but not limited to increased ocular redness, discomfort, or reduction in vision occur. Pt understood all instructions. Provided pt with BEVC office number for same day appointment scheduling & number for on-call doctor after hours. Edu patient on importance of returning to clinic for scheduled follow ups & obtaining required diagnostic testing in order to prevent permanent ocular health damage & to prevent permanent vision reduction/blindness.
If applicable, parent(s)/guardian(s) were informed on the above information.
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Edu patient on importance of returning to clinic for scheduled follow ups & obtaining required diagnostic testing & maintaining compliance with prescribed medications (if indicated) and/or following up with referred specialist (if indicated) in order to prevent permanent vision & ocular health damage/reduction/blindness.
If applicable, parent(s)/guardian(s) were informed on the above information.
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Edu patient on importance of returning to clinic for scheduled follow ups & obtaining required diagnostic testing in order to prevent permanent ocular health damage & to prevent permanent vision reduction/blindness.
If applicable, parent(s)/guardian(s) were informed on the above information.
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New spec rx was released, RTC in 1 yr for CEE or earlier if symptoms arise.
Edu pt on risk of retinal detachments, holes, breaks, and tears. Edu pt on signs/symptoms of retinal detachment including but not limited to sudden onset and/or increase in frequency of floaters and flashes & curtaining/reduction in vision. Edu pt to RTC asap if such symptoms arise for an immediate fundus evaluation.
If applicable, parent/guardian was also educated on the above information.
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No spec rx at this time. Return to clinic for scheduled follow up(s) (if any), then RTC 1 yr for CEE, unless symptoms arise sooner. Edu pt on risk of retinal detachments, holes, breaks, and tears. Edu pt on signs/symptoms of retinal detachment including but not limited to sudden onset and/or increase in frequency of floaters and flashes & curtaining/reduction in vision. Edu pt to RTC asap if such symptoms arise for an immediate fundus evaluation.
If applicable, parent/guardian was also educated on the above information.
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Released new spec rx, RTC for scheduled follow up(s) and then RTC in 1 yr for CEE or earlier if symptoms arise.
Edu pt on risk of retinal detachments, holes, breaks, and tears. Edu pt on signs/symptoms of retinal detachment including but not limited to sudden onset and/or increase in frequency of floaters and flashes & curtaining/reduction in vision. Edu pt to RTC asap if such symptoms arise for an immediate fundus evaluation.
If applicable, parent/guardian was also educated on the above information.
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CLs wearer NEW: Edu pt on contact lens modality and appropriate length of wear. Pt demonstrated good I&R skills in office today after receiving proper training. Edu pt on how to clean and care for contact lenses & maintain proper CLs hygiene. Edu pt to use multi-purpose contact lens solution for lens care (rec'd Biotrue & OptiFree PureMoist). Edu pt to not sleep, swim, or shower in CLs. Edu pt to immediately discontinue CLs wear & RTC same day for an evaluation if ocular redness, discomfort, or reduction in vision occur. Pt understood all instructions.
If applicable, parent/guardian was also educated on the above information.
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CLs Wearer: Edu pt on contact lens modality and appropriate length of wear. Edu pt on how to clean and care for contact lenses & maintain proper CLs hygiene. Edu pt to use multi-purpose contact lens solution for lens care (rec'd Biotrue & OptiFree PureMoist). Edu pt to not sleep, swim, or shower in CLs. Edu pt to immediately discontinue CLs wear & RTC same day for an evaluation if ocular redness, discomfort, or reduction in vision occur. Pt understood all instructions.
If applicable, parent/guardian was also educated on the above information.
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Edu pt on risk of retinal detachments, holes, breaks, and tears. Edu pt on signs/symptoms of retinal detachment including but not limited to sudden onset and/or increase in frequency of floaters and flashes & curtaining/reduction in vision. Edu pt to RTC asap if such symptoms arise for an immediate fundus evaluation.
If applicable, parent/guardian was also educated on the above information.
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Conj growth: photo taken & uploaded. Edu pt to RTC asap if changes are observed in size, texture, and/or dimension and edu pt on importance of monitoring condition to rule out malignant etiology / ocular damage/blindness.
If applicable, parent(s)/guardian(s) were informed on the above information.
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Iris nevus, photo taken & uploaded. Edu pt to RTC asap if changes are observed and edu pt on importance of monitoring condition to rule out malignant etiology / ocular damage/blindness. Edu pt to RTC 1 yr for monitoring.
If applicable, parent/guardian was also educated on the above information.
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Specialist: Refer to specialist for further evaluation/treatment. Edu pt that the specialist's office will contact pt to schedule an appointment. If no response from the office in 1 mo, edu pt to contact the office directly to schedule an appointment. Provided pt with office contact information.
If applicable, parent/guardian was also educated on the above information.
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Refer pt to specialist for further evaluation/treatment. Provided pt with date, time, location, and contact info for specialist appointment. Edu pt on importance of follow up with specialist to prevent any possible permanent damage/loss to vision and/or ocular health. Records were sent to the specialist's office via fax. Pt understood all instructions & importance of follow up.
If applicable, parent/guardian was also educated on the above information.
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Steroid Responder: RTC for IOP check. Edu pt on importance of returning for f/u visit to prevent vision loss associated with elevated IOPs.
If applicable, parent/guardian was also educated on the above information.
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Cataract: Edu pt on exam findings and condition. Pt was counseled that cataracts will progressively limit BCVA without surgical intervention. Pt was cautioned about driving and glare, especially at night. No surgical intervention is needed at this time - recommended waiting until functional vision is worse. Continue to monitor the condition as directed. If ADL's become impacted sooner than follow up appointment, patient edu to RTC for an examination.
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DFE decline: Edu pt on importance of dilating the pupils to obtain better view of fundus. Edu pt that without dilation, only limited view of retina is possible. Edu pt on risks associated with not dilating (including possible permanent vision loss due to a limited view of fundus) and pt understood all instructions & risks involved. Despite discussion & explanation of risks involved, pt decided to decline dilation.
If applicable, parent/guardian was informed on above information.
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Diabetes w/o ocular complications: No diabetic related ocular complications observed today upon fundus examination.
RTC for scheduled follow up, unless symptoms arise sooner.
Edu pt on condition and exam findings and counselled pt on possibility of diabetic changes to the eye if underlying systemic condition is not controlled. Recommended pt to continue following up with PCP & follow PCP treatment plan for systemic care.
If applicable, parent/guardian was also educated on the above information.
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Dry Eye: Edu pt on condition and exam findings. Prescribed ATs to be used tid OU. Advised effects of ceiling fans. Emphasized to pt importance of lid hygiene as directed. RTC for f/u as indicated.
If applicable, parent/guardian was also educated on the above information.
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Eye Strain: Edu pt on condition and exam findings. Discussed with pt that symptoms are consistent with eye strain secondary to prolonged near work. Recommended patient implement the 20-20-20 rule into their daily work routine. Also recommended for pt to keep ATs near desk to be used prn.
If applicable, edu parent/guardian on above findings as well.
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Eyelid growth: Growth has very low risk of malignant transformation. Edu pt on importance of self-monitoring condition for changes & to RTC if any changes are observed in color, texture, dimension, and size. Reviewed findings with patient & emphasized the need for yearly monitoring (or earlier if symptoms arise) to rule out malignant transformation that could lead to ocular damage/blindness.
If applicable, parent/guardian was also educated on the above information.
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Glc Suspect: POAG suspect based on ______.
Edu pt on exam findings. IOP lowering treatment is not indicated at this time; continue to monitor condition as directed. Edu pt on importance of returning to clinic for special testing/scheduled follow-ups to rule out glaucoma progression (if diagnosis is made) & to prevent permanent vision loss/blindness associated with glaucoma.
If applicable, parent/guardian was also educated on the above information.
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HAs: Edu pt on condition & exam findings. Edu pt on possible etiologies for HA (including possible pathological etiologies). Edu pt to continue to monitor for changes in symptoms such as but not limited to an increase in frequency/severity of HAs. Edu pt that if condition persists and/or does not improve after 1 month, to consult with pt's PCP to determine cause of HAs. Pt understood all instructions and importance of following up with PCP if HAs persist.
If applicable, parent/guardian was also educated on the above information.
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HR Growth: Edu pt on importance of self-monitoring condition for changes & to RTC if any changes are observed in color, texture, dimension, and size. Monitor condition. Reviewed condition & exam findings with patient and emphasized the need for monitoring to rule out malignant transformation/potential. Pt understood all instructions & importance of monitoring.
If applicable, parent/guardian was also educated on the above information.
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Hypertensive Retinopathy: Based on the clinical findings today, recommended pt continue to PCP for systemic care and follow up with eye exams as directed. Emphasized to the pt the importance of systemic control of underlying conditions. Pt edu about today's exam findings and counseled about the nature of hypertensive changes to the eye.
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Nevus: Very low risk of malignant transformation with lesion being flat, no SRF, no orange pigment, regular margins, & pt is asymptomatic. Monitor condition yearly for changes in color, texture, dimension, and size & for pt symptoms. Reviewed condition & exam findings with patient and emphasized the need for monitoring (or earlier if symptoms arise) to rule out malignant transformation. Pt understood all instructions.
If applicable, parent/guardian were also educated on the above information.
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Ocular Hypertension (HTN): IOP lowering treatment is not indicated at this time; continue to monitor condition as directed with IOP checks & OCT ONH OU. Edu pt on condition & exam findings. Edu pt on importance of monitoring condition & returning for scheduled follow ups in order to rule out pathological etiologies such as but not limited to glaucoma & to prevent permanent vision loss & blindness.
If applicable, parent/guardian was also educated on the above information.
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POAG Surgical Referral: Pt is not meeting target IOP pressures in office today despite use of topical medications with good compliance - see chart notes for more details. SLT surgery indicated at this time - refer pt to ophthalmologist specializing in glaucoma for consult and procedure. Risks and benefits of surgical procedure were discussed with pt in office. Instructed pt to continue using topical IOP lowering medications as prescribed. RTC for special glaucoma testing as directed.
Edu pt on exam findings. Advised pt on risk of vision loss associated with glaucoma & need for treatment compliance.
If applicable, parent/guardian was also educated on the above information.
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POAG suspect based on ____. IOP lowering treatment is not indicated at this time; continue to monitor condition as directed. RTC for special testing to rule out glaucoma progression.
Edu pt on exam findings. Advised pt on risk of vision loss associated with glaucoma & edu pt on need for treatment & testing/follow-up compliance to prevent permanent vision loss associated glaucoma.
If applicable, parent/guardian was also educated on the above information.
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POAG, continue treatment: Pt is meeting target IOP in office today - see chart notes for more details. Continue treatment with topical IOP lowering medication as directed. RTC for special glaucoma testing as directed.
Edu pt on exam findings. Advised pt on risk of vision loss associated with glaucoma & need for treatment compliance (including compliance with scheduled follow ups) to prevent permanent vision loss.
If applicable, parent/guardian was also educated on the above information.
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1 Day PO cat sx:
Educated pt about findings. Use medications as prescribed. RTC for 1 week post op. Edu pt to call clinic STAT if signs/symptoms occur outside of the expected discussed in office today - this includes but is not limited to decreasing vision and significant pain.
Reminded pt of post-operative instructions for the next 1 week:
No heavy lifting (over 10 lbs). No strenuous activity including exercising. No rubbing of the eyes. Avoid direct water into the eyes.
Wear the plastic eye shield at bedtime for the first four (4) nights. Wear sunglasses when outdoors. Avoid dusty environments.
Patient understands that complications and/or infection(s) can occur if patient does not adhere to the treatment plan prescribed by the doctor. Pt understands the importance of returning for scheduled post-op visits to prevent ocular complications.
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1 Week cat sx PO:
Edu pt about findings and all post-operative instructions. Edu pt that all post-operative restrictions have been removed. Edu pt to d/c antibiotic coverage. Use other medications as prescribed. Edu pt to call clinic STAT if signs/symptoms occur outside of the expected discussed in office today - this includes but is not limited to decreasing vision and significant pain.
RTC for 1 mo cat sx PO. RTC sooner if new symptoms occur.
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1 Month cat PO:
New spec rx was released. Examination revealed a flat & intact fundus OU. Pt was educated to RTC asap if redness, pain, or reduction/changes in vision occur. Edu pt on risk of retinal detachments, holes, breaks, and tears following cataract surgery. Edu pt on signs/symptoms of retinal detachment including but not limited to sudden onset and/or increase in frequency of floaters and flashes & curtaining/reduction in vision. Edu pt to RTC asap if such symptoms arise for an immediate fundus evaluation.
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Acute Flashes/floaters: Discussed condition & exam findings and possible & probable causes for floaters & flashes. Reviewed signs and symptoms of retinal tear/detachment and the importance of prompt evaluation should there be an increase in floaters, flashes of light, or decreasing peripheral vision. Provided pt with clinic on call doctor phone number to call if emergency arises for same day evaluation. Pt understood all instructions.
If applicable, parent/guardian was also educated on the above information.
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Acute PVD: Pt was counseled on the importance of monitoring the condition as directed. Pt understands changes are normal for age. Instructed pt to immediately report any change in condition outside of expected and discussed symptoms. Stressed need to RTC ASAP if acute signs/symptoms of RD are experienced such as but not limited to new onset flashes of light and/or floaters, increased frequency of floaters and/or flashes, or curtaining/reduction of vision. Provided patient with contact information to BEVC for same day scheduling if emergency occurs and provided pt with information on how to reach on-call doctor at BEVC for office after hours emergency.
Edu pt that floaters and flashes should not be worsening over time, RTC asap (sooner than follow up) if they do. Pt acknowledged understanding of condition and all instructions provided in office. Edu pt on importance of returning to clinic for PVD follow up.
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Allergic Conjunctivitis: Edu pt on condition and exam findings. Prescribed topical steroid and allergy drop to be used as directed. Recommended use of ATs as needed. Discussed use of allergy drop and oral allergy medications PRN. Follow up as directed and RTC if any symptoms outside those discussed today are noted.
If applicable, parent/guardian was educated on the above information as well.
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Atropine/Myopia Control: After discussion with parent regarding myopia control options & the risks/benefits of each treatment option, parent decided to begin use of Atropine eye drops. Edu parent that atropine is not FDA approved at this time (edu parent that this is an off-label use of the medication) and edu pt & parent on possible side effects associated with atropine use - both systemic and ocular. Pt/parent understood all instructions and risks involved with initiation of medication. Parent would like to proceed with atropine use. Edu pt/parent to call the clinic asap (sooner than the scheduled follow up appointment) for an urgent evaluation & to discontinue the medication if unexpected symptoms arise. Edu pt/parent on what symptoms to be aware of that would require an immediate evaluation. Edu pt/parent on how to use medication (qhs in both eyes) and purpose of using the medication. Pt/parent understood all instructions.
RTC for atropine myopia control follow up, then consider follow up every 6 months.
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Cataract, continue to monitor: Pt was counseled that cataracts will progressively limit BCVA without surgical intervention. Pt was cautioned about driving and glare, especially at night. No surgical intervention is needed at this time - recommended waiting until functional vision is worse. Edu pt on exam findings and condition. Continue to monitor the condition as directed. If ADL's become impacted sooner than follow up appointment, patient edu to RTC for a cataract sx evaluation.
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Cataract (surgery deferred by pt): Edu pt on condition and exam findings. Pt was counseled that cataracts will progressively limit BCVA without surgical intervention. Pt was cautioned about driving and glare, especially at night. Pt was counseled about the risks and benefits of surgery and IOL options. After discussion, the pt elected to defer cat sx at this time. Edu pt on importance of monitoring the condition.
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Cataract (surgery referral): Edu pt on condition and exam findings. Pt was counseled that cataracts will progressively limit BCVA without surgical intervention. Pt was counseled about the risks and benefits of surgery and IOL options. After discussion, pt elected to proceed with cat sx with a standard PCIOL for distance (target plano) and rx pseudophakia specs.
Referral of pt was made for cataract surgery. Pt was provided information to surgery center. RTC for post-operative care and pseudophakia care as directed.
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Cranial Nerve Palsy: Edu pt on condition and exam findings. Counseled pt on importance of monitoring condition as directed. Stressed importance of BG and BP control. Pt may use an occlusion patch over one eye to relieve symptomatic diplopia. Instructed pt to immediately report any change in condition outside of expected and discussed symptoms. MRI of head is not indicated at this time but should be considered if new neurologic signs or symptoms develop or the severity of the palsy increases. RTC for additional testing as indicated.
If applicable, parent/guardian was educated on the above information as well.
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Crowded Disc at Risk for Non-Arteritic Anterior Ischemic Optic Neuropathy (NAION): BP measured in office WNL. Edu pt on importance of controlling BP and maintaining regular f/u with PCP for systemic control of any vasculopathy conditions. Edu pt on condition and exam findings. Monitor yearly with fundus evaluation, unless symptoms such as suddenly reduced VA or significant changes in vision arise, then RTC sooner.
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Diabetes with ocular complications: Edu pt on condition and exam findings. Counseled pt on risk of vision loss if underlying condition is not controlled. Emphasized importance of systemic blood glucose control. Pt to RTC for monitoring and imaging services as indicated.
RTC for scheduled follow up, unless symptoms arise sooner.
Continue to monitor with fundus evaluation and consider OCT testing at next f/u.
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Diabetic Retinopathy (proliferative):
Edu pt on condition and exam findings. Counselled pt on risk of blindness and the importance of treating the underlying systemic condition. Emphasized to pt importance of systemic blood glucose control. Report was sent to pt's PCP regarding ocular findings. Pt referred to an ophthalmologist specializing in vitreo-retinal care for surgical intervention. Pt counseled on use of anti-VEGF and/or retinal laser for treatment of retinopathy; risks and benefits of treatment were discussed with the patient. Pt scheduled to RTC for monitoring and imaging services as indicated.
Appointment has been scheduled with retinal specialist. Pt understands cost associated with treatment and was provided detailed information in clinic today about when/where to proceed for surgical intervention.
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Hordeolum: Prescribed oral medication to be used as directed and warm compress to be used 2-3x/day until resolution. Emphasized to pt the importance of lid hygiene. Advised ATs may be used as needed for ocular surface lubrication.
Edu pt on exam findings. RTC for follow up as indicated.
If applicable, parent/guardian was also educated on the above information.
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Keratoconus: Provided pt with updated spec rx but edu that optimal vision will not be obtained with specs only. Recommended pt proceed with specialty CLs fitting for optimal vision - after discussion with pt, follow up for RGP fitting was scheduled. Edu pt regarding condition and exam findings. Pt edu about all treatment options and was informed that there are no current surgical procedures available to cure the condition but may be considered in the future if progression is noted on topography / MR testing.
If applicable, parent/guardian was also educated on the above information.
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Lattice: Patient understands that lattice with or without holes indicates that retinas are more fragile in nature and thus pose a higher risk of tears, breaks, and detachments. Patient understands that acute changes to vision or floaters with or without flashes of light could indicate a retinal compromise and should seek immediate care with an eye care provider. Pt understands that yearly fundus evaluations are necessary to appropriately monitor condition. F/u in 12 months or PRN.
If applicable, parent/guardian were also educated on the above information.
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Lid Growth/Papilloma: Continue to monitor lid growth. Edu pt to observe for any changes including but not limited to color, size, shape, or texture. If pt notices changes or has associated symptoms, RTC for prompt evaluation, otherwise monitor yearly.
If applicable, parent/guardian was also educated on the above information.
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Macular Hole: Edu pt on condition and exam findings and explained reason for reduced vision is due to the macular hole. Due to the acute nature of the condition, recommended surgical referral for vitrectomy. Emphasized to pt that delay in surgical repair could result in reduced success in hole closure and visual benefit/recovery. Informed pt that vision does not typically return to "normal" even after hole closure. Edu pt that there is a remote chance of spontaneous macular hole closure if surgery is not performed. Expected visual outcome s/p surgical repair was also discussed and the pt understands that even with a successful surgery, residual visual blur and metamorphosis may persist. Edu pt on statistically a 10-15% chance of a macular hole developing in the fellow eye.
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Narrow Angle: Discussed nature of condition and related risks of acute angle closure that could potentially cause irreversible vision loss. Reviewed associated symptoms of an acute angle closure (HAs, vomiting, pain, etc...) attack, in which such an event should be considered an ocular emergency that would require urgent medical care. Edu pt to take caution when transitioning from dark to light environments such as when leaving a movie theater. Consider DFE only after performing gonioscopy.
Monitor with gonioscopy & anterior segment OCT.
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Pinguecula: Recommended consistency with BID artificial tears to avoid dryness, irritation, and inflammation. Recommend patient continue with UV protection eye wear.
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Pterygium: Recommended consistency with BID artificial tears to avoid dryness, irritation, and inflammation. Recommend patient continue with UV protection eye wear.
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Pterygiumitis/Pingueculitis: Recommended use of UV protection and ATs QID. Edu pt to RTC if symptoms worsen. Edu pt on condition and exam findings.
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Subconjunctival Hemorrhage: Pt was counseled on the importance of monitoring the condition as directed. Pt may use ATs PRN and was advised to avoid blood thinning medications to promote quicker resolution. Instructed pt to immediately report any change in condition outside of expected and discussed symptoms. RTC if not resolved in 2-3 weeks or if reoccurrence is noted. Edu pt on condition and exam findings.
If applicable, parent/guardian was also educated on the above information.
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Vitrectomy: Edu pt on condition and exam findings. Edu pt regarding surgical treatment option of a vitrectomy including what to expect during the procedure, the risks/benefits/advantages, and the expected recovery process. Pt understands a general recovery of at least 3-4 weeks is expected s/p vitrectomy which includes (but not limited to) avoiding activities that may cause the head to move and keeping the head in a specific position for most of the day and night for 1-3 weeks s/p vitrectomy. Pt is aware that the surgeon will provide specific and more detailed instructions regarding the recovery time.
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YAG Referral: Refer to ophthalmologist for YAG cap to improve BCVA. Pt counseled about the risk and benefits of the laser procedure. After discussion, pt elects to proceed with surgical referral. Referral of pt was made for YAG cap. Pt was provided information in clinic today. RTC for post-operative care as directed. Pt was educated on condition and exam findings.
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Foreign Body Removal: Foreign body removed in office today using 25 gauge needle. Proparacaine was instilled in OD prior to removal. 1 gtt Polytrim was instilled OD after FB removal. BSCLs was applied to the affected eye (brand: ____). Patient was prescribed topical ophthalmic medication (AB: _____) to be used as directed. RTC for foreign body subsequent encounter as directed. Edu pt to RTC sooner than scheduled f/u if symptoms do not improve or if they worsen including but not limited to increased pain, redness, or changes/ reduction in vision. Provided pt with emergency on call doctor phone number.
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AMD: Monitor with in-office diagnostic testing, and at home with monocular Amsler grid or equivalent. Recommend over-the-counter AREDS2 vitamin supplement po bid. RTC immediately with any changes in vision.
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