Diabetic Retinopathy Evaluation Note

Date: [Date of encounter]

Patient Name: [Full name]

Date of Birth: [DOB]

Clinician: [Clinician name and credentials]

Location: [Clinic/site]

Encounter Type: [new / established]; [screening / surveillance / symptomatic]

Reason for Visit: [Reason for visit]

Chief Complaint

[Chief complaint] (Use patient's own words when symptom-driven.)

History of Present Illness

[Narrative HPI] (Include visual symptoms if present—onset, duration, laterality, severity, floaters, flashes, metamorphopsia, scotoma—and functional impact. Document prior diabetic retinopathy status and treatments—prior staging, panretinal photocoagulation, intravitreal injections with agent and timing, vitrectomy, last eye exam date. Include diabetes context—type, duration, current therapy, most recent A1c with date labeled as measured vs patient-reported, blood pressure control, relevant complications such as CKD/dialysis or pregnancy. Note urgent symptoms if present—sudden vision loss, new floaters/flashes, curtain/shadow, eye pain. When information is unavailable, state "Unknown," "Patient unsure," or "Records unavailable" rather than omitting.)

Relevant History

Medical History: [Relevant systemic conditions] (Diabetes type/duration if not in HPI, hypertension, hyperlipidemia, CKD, cardiovascular disease, pregnancy status, smoking status, recent rapid glycemic intensification if applicable.)

Ocular History: [Prior eye diagnoses and surgeries] (Glaucoma, cataract, AMD, retinal vein occlusion, uveitis; prior surgeries—cataract/IOL, vitrectomy, refractive; prior trauma.)

Medications: [Relevant medications and allergies] (Ocular medications—especially steroids and IOP-lowering agents—and anticoagulants/antiplatelets. Note relevant allergies with reaction type.)

Examination

[Exam performed dilated / undilated]; [Dilation agent and time if applicable]. [Limitations if any: small pupil / media opacity / poor cooperation / none]

Vision and Ocular Metrics

• Visual Acuity (corrected) — OD: [VA]; OS: [VA]
• Pinhole (if indicated) — OD: [VA]; OS: [VA]
• Intraocular Pressure — OD: [IOP] [method]; OS: [IOP] [method]
• Pupils — OD: [size/reactivity]; OS: [size/reactivity]; RAPD: [present / absent / unable to assess]
• Confrontation Visual Fields (if indicated) — OD: [findings]; OS: [findings]

Anterior Segment

• Lids/Conjunctiva — OD: [findings]; OS: [findings]
• Cornea — OD: [findings]; OS: [findings]
• Anterior Chamber — OD: [depth, cell/flare]; OS: [depth, cell/flare]
• Iris — OD: [findings]; NVI/NVA: [present / absent]; OS: [findings]; NVI/NVA: [present / absent]
• Lens — OD: [status and cataract severity if present]; OS: [status and cataract severity if present]

Posterior Segment

• Vitreous — OD: [clear / hemorrhage / haze / traction]; OS: [clear / hemorrhage / haze / traction]
• Optic Nerve — OD: [C/D ratio, NVD present / absent, pallor, other findings]; OS: [C/D ratio, NVD present / absent, pallor, other findings]
• Macula — OD: [thickening / hard exudates / hemorrhages / clinically apparent edema / normal]; OS: [thickening / hard exudates / hemorrhages / clinically apparent edema / normal]
• Vessels/Periphery — OD: [microaneurysms, dot-blot hemorrhages, venous beading, IRMA, NVE, PRP scars, fibrovascular proliferation, tractional changes, retinal detachment, or normal]; OS: [findings]

Imaging and Interpretation

(Include only for tests performed. For each test, document indication, laterality, image quality, key findings, comparison to prior if available, and interpretation. Label outside studies as "Outside imaging reviewed.")

OCT Macula

• Indication: [reason]; Laterality: [OD / OS / OU]; Quality: [adequate / limited]
• Findings: [intraretinal fluid / subretinal fluid / cysts / ERM / VMT / normal]; CST: [value µm]
• Comparison to prior: [interval change / stable / new baseline]
• Interpretation: Center-involved DME [present / absent]; [additional clinical correlation]

Fundus Photography / Widefield Imaging

• Indication: [reason]; Laterality: [OD / OS / OU]; Quality: [adequate / limited]
• Findings: [key lesions and distribution supporting DR staging]
• Comparison to prior: [interval change / stable / new baseline]

Fluorescein Angiography or OCT-A

• Indication: [unclear neovascularization / unexplained vision loss / ischemia evaluation / other]
• Laterality: [OD / OS / OU]; Quality: [adequate / limited]
• Findings: [ischemia / capillary nonperfusion / leakage / neovascularization]
• Interpretation: [clinical significance for staging/treatment]

B-scan Ultrasound

• Indication: [media opacity limiting view / other]; Laterality: [OD / OS / OU]
• Findings: Retina [attached / detached]; [tractional elements / vitreous hemorrhage / other]
• Interpretation: [implications for management]

Assessment

(Problem-oriented, ordered by clinical priority. Always document DR severity and DME status; if staging limited, state limitation explicitly with plan to address.)

Diabetic Retinopathy Severity

Classification: International Clinical Diabetic Retinopathy scale

• OD: [No apparent DR / Mild NPDR / Moderate NPDR / Severe NPDR / PDR] — [key supporting findings or limitation preventing staging]
• OS: [No apparent DR / Mild NPDR / Moderate NPDR / Severe NPDR / PDR] — [key supporting findings or limitation preventing staging]

Diabetic Macular Edema Status

• OD: DME [present / absent]; [center-involved / non-center-involved]; VA [value]; tractional component [present / absent]
• OS: DME [present / absent]; [center-involved / non-center-involved]; VA [value]; tractional component [present / absent]

Additional Problems

• [Problem with laterality] — [assessment and differential if atypical]

Plan

DR Management

• [Observation with interval / referral (routine vs urgent) / treatment (PRP / anti-VEGF / vitrectomy)] — [rationale]
• [If treatment performed today: reference separate procedure note]

DME Management

• [For CI-DME with preserved VA: shared decision-making discussion regarding observation vs treatment, monitoring plan]
• [For CI-DME with vision loss: treatment plan with agent/regimen, alternatives considered, monitoring approach]
• [For non-CI-DME: observation vs focal laser consideration]

Systemic Risk Factor Counseling

[Counseling provided regarding glycemic control, blood pressure, and lipid management to reduce DR progression risk. Pregnancy-specific counseling if applicable.]

Return Precautions

Patient instructed to return promptly for new floaters, flashes, curtain/shadow in vision, sudden vision change, or eye pain/redness.

Follow-up

[Specific timeframe] for [planned testing—dilated exam, OCT macula, other]; sooner PRN for symptoms.

Care Coordination

[Communication with diabetes care clinician]: [PCP/endocrinologist name if known] will be notified of DR severity, DME status, and follow-up plan via [letter / EHR message / fax]. (If communication cannot occur, document reason and remediation plan.)