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Doctor Of Optometry
15-20 minutes

Optometry Report

The s10.ai Optometrist's note template is expertly crafted for documenting detailed eye examinations, featuring sections for subjective complaints, objective findings, assessments, and treatment plans. Optometrists can efficiently record critical details such as visual acuity, intraocular pressure, and anterior and posterior segment findings. This template also accommodates family ocular history, medication history, and any additional tests conducted, ensuring comprehensive documentation. By facilitating accurate diagnosis and treatment planning, this structured format is perfect for optometrists seeking to streamline their documentation process, ultimately enhancing patient care and follow-up management. Explore the s10.ai template to optimize your clinical workflow today.

2,679 uses
4.4/5.0
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Dr. Emily Carter
Template Structure

Organized sections for comprehensive clinical documentation

Subjective:
- Chief Complaint: [Brief description of the reason for the visit (only include if applicable)]
- History of Present Illness: [Details about the onset, duration, severity, and character of the visual complaint (only include if applicable)]
- Past Ocular History: [History of eye diseases, surgeries, treatments, and outcomes (only include if applicable)]
- Medical History: [Relevant systemic conditions affecting ocular health (only include if applicable)]
- Medication History: [Current ocular and systemic medications (only include if applicable)]
- Allergies: [Medication and substance allergies (only include if applicable)]
- Family Ocular History: [Eye diseases in the family (only include if applicable)]
- Social History: [Tobacco, alcohol use, and occupational hazards (only include if applicable)]
Objective:
- Visual Acuity: [Without correction, With correction (OD, OS) (only include if applicable)]
- Retinoscopy:
- Intraocular Pressure: [Measurement method, values (OD, OS) state if they are within normal limits between 8 - 21 mmHg or is it borderline high ie ocular hypertension at 22-23mmHg or is it at the referrable limit of a routine referral 24-31 or does it need a urgent referral 32-42mmhg or is it an emergency 42+ (only include if applicable)]
Anterior Segment: [Findings from slit-lamp examination (only include if applicable)]
- Lids and lashes: [Clean and clear, Crusting, MGD, state both eyes OU if eyes aren't discussed individually (only include if applicable)]
- Cornea: [ Clear, or are there opacities like scarring from previous foreign bodies, Any staining with fluoroscein state both eyes OU if eyes aren't discussed individually (only include if applicable)]
- Anterior Chamber: [Any cells or flare, are the anterior chamber angles open (only include if applicable)]
- Pupil Reactions: [PERRLA, RAPD, Adie's, Horner's, Marcus Gunn Pupil (only include if applicable)]
- Media: [clear no cells, floaters visible, no shaffer's sign present that may indicate a retinal detachment state both eyes OU if eyes aren't discussed individually (only include if applicable)]
- Lens: [clear, cortical cataract, nuclear sclerosis, brunescence, posterior subcapsular, anterior vacuoles. state both eyes OU if eyes aren't discussed individually (only include if applicable)]
Posterior Segment:
- Macula: [good colour, healthy appearance, state both eyes OU if eyes aren't discussed individually(only include if applicable)]
- Peripheral retina: [Flat & normal, no tears or holes, state both eyes OU if eyes aren't discussed individually(only include if applicable)]
- Optic Discs: [C/D ratios, colour, Neuroretinal rim, any notches, RNFL - any defects such as wedge. state both eyes OU if eyes aren't discussed individually (only include if applicable)]
- Retinal Vessels: [Normal appearance, tortuous, nipping present, 2/3, 1/2 artery to vein ratio, state both eyes OU if eyes aren't discussed individually(only include if applicable)]
[Findings from fundus examination, were dilating drops used? (only include if applicable)]
- Additional Tests: [Visual fields, OCT, fluorescein angiography results (only include if applicable)]
Assessment:
- Binocular Refraction: [BV present, Fixation Disparity - Horizontal lines level, vertical lines level one above each other means Ortho, Esophoria Exophoria, Hyperphoria for Distance and Near, BV not present - Eye suppression, Motility SAFE Smooth, accurate, full, extensive or muscle problem found (only include if explicitly mentioned)]
- Refraction: [Duochrome balanced or on red or on green, +1.00 Blur test blurs vision up]
- [Diagnosis with ICD-10 code (only include if explicitly mentioned)]
- [Differential diagnoses (only include if applicable)]
Plan:
- Dispensing recommendations [Single vision, distance, reading, bifocals, varifocals, high index, toughened lenses, office spectacles, miyosmart lenses]
- Treatments: [Medications, laser, or surgical interventions planned (only include if applicable)]
- Follow-Up: [Interval until next visit and conditions for sooner return (only include if applicable)]
- Patient Education: [Information given about diagnosis, treatment, and prognosis (only include if applicable)]
- Referrals: [Referrals to other specialists if needed (only include if applicable)]
- Issued prescription for glasses [OD Sphere, Cylinder, Axis, Distance Prism, VA, Near Add, Near Prism, Near VA, OS Sphere, Cylinder, Axis, Distance Prism, VA, Near Add, Near Prism, Near VA]
Sample Clinical Note

Example of completed documentation using this template

Subjective:
- Chief Complaint: Blurred vision in the right eye
- History of Present Illness: The patient describes experiencing blurred vision in the right eye for the last two weeks, without any pain or redness.
- Past Ocular History: Myopia history, no prior surgeries or treatments.
- Medical History: Hypertension, effectively managed with medication.
- Medication History: Lisinopril 10mg daily.
- Allergies: No known drug allergies.
- Family Ocular History: Father diagnosed with glaucoma.
- Social History: Non-smoker, occasional alcohol consumption, employed as a computer programmer.
Objective:
- Visual Acuity: Without correction: OD 6/12, OS 6/6; With correction: OD 6/6, OS 6/6
- Retinoscopy: OD: -2.00 DS, OS: -1.50 DS
- Intraocular Pressure: OD 18 mmHg, OS 17 mmHg, within normal limits
Anterior Segment:
- Lids and lashes: Clean and clear OU
- Cornea: Clear OU
- Anterior Chamber: Angles open, no cells or flare OU
- Pupil Reactions: PERRLA OU
- Media: Clear, no floaters or Shaffer's sign OU
- Lens: Clear OU
Posterior Segment:
- Macula: Good colour, healthy appearance OU
- Peripheral retina: Flat & normal, no tears or holes OU
- Optic Discs: C/D ratio 0.3 OU, healthy neuroretinal rim OU
- Retinal Vessels: Normal appearance, 2/3 artery to vein ratio OU
Findings from fundus examination: No dilating drops used
- Additional Tests: Visual fields normal, OCT shows normal retinal thickness
Assessment:
- Binocular Refraction: BV present, Fixation Disparity - Ortho for Distance and Near
- Refraction: Duochrome balanced
- Diagnosis with ICD-10 code: Myopia (H52.1)
Plan:
- Dispensing recommendations: Single vision lenses
- Treatments: None required at this time
- Follow-Up: Return in 12 months for routine check-up
- Patient Education: Discussed the importance of regular eye exams and maintaining good ocular health
- Referrals: None
- Issued prescription for glasses: OD Sphere -2.00, Cylinder 0.00, Axis 0, Distance Prism 0, VA 6/6, Near Add +1.00, Near Prism 0, Near VA N5; OS Sphere -1.50, Cylinder 0.00, Axis 0, Distance Prism 0, VA 6/6, Near Add +1.00, Near Prism 0, Near VA N5
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the documentation process for eye care professionals, ensuring thorough and accurate patient records. It covers all essential aspects of an ocular examination, from the subjective history, including chief complaints and past ocular history, to objective findings such as visual acuity, intraocular pressure, and detailed anterior and posterior segment evaluations. The template also includes sections for additional tests like OCT and fluorescein angiography, as well as assessments and plans for treatment, follow-up, and patient education. By adopting this template, clinicians can enhance their workflow efficiency, improve patient care, and ensure compliance with clinical standards. Explore this template to optimize your practice's documentation and patient management strategies.
Frequently Asked Questions

Common questions about this template and its usage

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