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This ophthalmology new patient visit (NPV) note template by s10.ai is crafted for ophthalmologists to meticulously document comprehensive eye exams. It features sections for patient history, objective findings, and diagnostic results, ensuring detailed documentation of ocular health. The template facilitates precise recording of visual acuity, intraocular pressure, and anterior and posterior segment findings, making it perfect for managing complex cases such as cataracts and glaucoma. By integrating with s10.ai, this template enhances the documentation process, promoting efficient and accurate record-keeping in ophthalmic practice.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
Date of Examination: 11/01/2024Reason for Visit:Diagnoses:- Cataract, unspecified: H25.9- Primary open-angle glaucoma, bilateral: H40.113- Chief Complaint: Blurred vision in both eyes- Extended HPI: 65-year-old Caucasian male, retired engineer, referred by Dr. Smith with a history of hypertension and diabetes, presenting with progressive blurred vision over the past six months, moderate in severity, impacting daily activities.A1C: 7.2Current Ocular Meds: Latanoprost once daily at bedtime, Timolol twice daily- Past Ocular History: Previous cataract surgery in the right eye, laser trabeculoplasty- Past Medical History: Hypertension, diabetes mellitus type 2- Past Surgical History: Appendectomy, cataract surgery in the right eye- Systemic Meds: Metformin, Lisinopril- Allergies: NKDA- Family Ocular History: Father had glaucoma- Social History: Non-smoker, occasional alcohol use, no occupational hazards- ROS: Just click default.Objective:- Dilation: Yes- Dominant Eye: OD- Visual Acuity: Without correction OD: 20/50, OS: 20/60; With correction OD: 20/30, OS: 20/40- Intraocular Pressure: Goldmann applanation, OD: 18 mmHg, OS: 20 mmHg- Pachymetry: Ultrasound, OD: 540 microns, OS: 550 microns- Refractions: OD: +1.00 -0.50 x 90, OS: +1.25 -0.75 x 85Special testing:- Red Desaturation: OD: Normal, OS: Normal- TBUT: OD: 8 seconds, OS: 7 seconds- Schirmer Tear: OD: 10 mm, OS: 9 mm- External-----> General: Symmetric Appearance-----> Pupils: Round and reactive OD, OS-----> Motility: Full range of motion OD, OS-----> CVF: Full to confrontation OD, OS-----> Adnexa: No abnormalities noted OD, OS- Anterior Segment:-----> General: Clear corneal graft OD, OS-----> L/C/S: No injection, clear conjunctiva OD, OS-----> Cornea: Clear OD, OS-----> A/C: Deep and quiet OD, OS-----> Iris: Normal OD, OS-----> Lens: PCIOL in great position OD, OS- Posterior Segment:-----> General: Clear view of posterior segment OD, OS-----> Nerve: Cup to disc 0.6 OD, OS-----> Vitreous: Clear OD, OS-----> Vessels: Normal caliber OD, OS-----> Macula: No edema OD, OS-----> Periphery: Attached OD, OSGonio:-----> Gonioscopy: Widely open to scleral spur 360 degrees OU w/no NVI/NVA notedDiagnostics:- OCT Macula: No macular edema OD, OS- OCT RNFL: Normal RNFL OD, OS- Corneal Topography: Normal study OD, OS- Fundus Photos: Confirms clinical findings OD, OSProcedures: NoneImpression and Plan:Diagnoses:- Cataract, unspecified: H25.9: Consider cataract surgery OS- Primary open-angle glaucoma, bilateral: H40.113: Continue Latanoprost and Timolol, monitor IOPFollow-Up: 3 months, sooner if vision worsensPatient Education: Discussed the nature of cataracts and glaucoma, treatment options, and prognosisReferrals: NoneMeds to be prescribed: NonePatient Pharmacy:Notes to Reg:Letters:Thanks you for your Kind referral of this wonderful patient!-------------------------------------------------------------------------------------Scheduling Call:- John Doe- 01/01/1959- Blurred vision- 555-123-4567- johndoe@example.com- 123 Main St, Anytown, USA- Glaucoma- Health Insurance: ABC Health- Preferred date and time for the call: 11/02/2024, 10:00 AM- Scheduled date and time for the in clinic appointment: 11/15/2024, 2:00 PM- Contact information (phone number, email): 555-123-4567, johndoe@example.com- Any specific questions or topics to be discussed during the call: Discuss cataract surgery options- Additional notes or instructions for the patient: Bring current medications to the appointment- Referring doctor: Dr. Smith- Preferred date and time for the call: 11/02/2024, 10:00 AM---------------------------------------------------------------------------- John Doe- 01/01/1959- Patient's MRN: 123456- Height: 180 cm- Weight: 85 kg- Ethnicity: Caucasian- Occupation: Retired Engineer- Patient's Phone number: 555-123-4567- Patient's Email Address: johndoe@example.com- Patient's Mailing Address: 123 Main St, Anytown, USA- Patient's health insurance information: ABC Health- Referring source: Dr. Smith- Primary care physician: Dr. Smith
Key advantages of using this template in clinical practice
Common questions about this template and its usage