Snider - EYE Exam

Chief Complaint

Medical Note Template -- Eye Complaint

CHIEF COMPLAINT

[Document the patient's primary eye-related complaint, including onset, duration, severity, and any associated symptoms.]

PMH

[Only include history related to the eye complaint. Provide details about any past medical history that is relevant to the current eye issue.]

RELEVANT MEDICATIONS

[Only include medications related to the eye complaint. List the medication name, dosage, and frequency if applicable.]

EYE EXAM

[Please include the following in bullet form, only if it is discussed: - Visual acuity: OD (right visual acuity), OS (left visual acuity) - Visual fields: [Indicate if full or decreased] - Pupils: [Document size in mm and whether RAPD is present or not] - Extra-ocular movements: [State if normal or if nystagmus is noted] - Slit lamp exam: [Include whether fluorescein was instilled and any other findings] - Lids, lashes, lacrimals: [Note if examined and any findings] - Sclera and conjunctivae: [Note color or if there is any discharge] - Corneas: [Document findings such as no fluorescein uptake or negative Seidel's test] - Fundoscopy: [If done, note findings such as papilledema, whether optic discs are sharp, evidence of retinal detachment, vitreous hemorrhage, or other abnormalities] - IOP (tonopen): OD (right pressure), OS (left pressure)]

IMPRESSION AND PLAN

[Provide the impression based on the findings from the eye exam. Include plans for ophthalmology follow-up, specifying the date and time, and instructions on when the patient should return for further evaluation.]