Glaucoma Evaluation Note (New Patient)

Date: [Encounter date]

Location: [Clinic/site]

Clinician: [Name, credentials]

Referral Source: [Self-referred / Optometrist / Ophthalmologist / PCP / Other] — [Reason for referral if applicable]

Data Sources: [Patient/caregiver history; outside records reviewed with source and date range; tests performed today] (Document "Unknown—records requested" or "Patient unsure" for missing relevant information rather than leaving blank.)

Chief Complaint

[Single-line medical necessity context, e.g., referral reason or trigger finding]

History of Present Illness

[Narrative 3–8 sentences covering: trigger for evaluation; relevant symptom review; prior eye care context including last exam and who noted concern; current glaucoma therapy status with adherence and tolerance if applicable] (Keep concise and clinically focused.)

Glaucoma History and Risk Factors

Ocular History: [Prior glaucoma-related diagnoses; prior ocular surgery or laser; trauma history; uveitis history; steroid exposure with route and timing; refractive status] (Document "Unknown—records requested" or "Patient unsure" for unknown but relevant items.)

IOP History: (Capture Tmax and context per eye.)

Date	OD (mmHg)	OS (mmHg)	Method	On treatment?	Source
[Date]	[Value]	[Value]	[GAT / iCare / Tono-Pen / Other]	[Yes / No / Unknown]	[Patient report / Outside records]

[Typical IOP range if known; prior IOP spikes and suspected cause; time-of-day patterns if documented]

Family History: [First-degree relatives with glaucoma with relationship; age at diagnosis or blindness history if known; or "Negative" / "Unknown"]

Relevant Systemic History: [Diabetes; hypertension; nocturnal hypotension; sleep apnea; migraine/Raynaud/vasospastic disorders; cardiopulmonary disease; pertinent neurologic history] (Include only details relevant to glaucoma risk or treatment decisions.)

Medications and Allergies:

• Current ocular medications: [Name, concentration, dosing, eye, start date, adherence, tolerance]
• Prior failed/intolerant drops: [Agent and reason]
• Relevant systemic medications: [Including steroids]
• Allergies: [Medication allergies with reaction type, or "NKDA"]

Review of Systems

(Include only if medically relevant to glaucoma evaluation or treatment safety.)

• Neuro: [Headaches, focal deficits, transient vision loss]
• Eye: [Pain, redness, halos, acute blur episodes]
• Respiratory/Cardiac: [Asthma/COPD, bradycardia] (Include if beta-blocker considered.)

Examination

(OD/OS labeling is mandatory for quantifiable findings. If an element was not performed, document "Not performed—[reason]" with plan to complete.)

Visual Acuity and Basic Exam

• Visual acuity: OD [Value, corrected/uncorrected] | OS [Value, corrected/uncorrected]
• Pupils: OD [Findings] | OS [Findings]; RAPD [Present OD / Present OS / Absent]
• Extraocular movements: [Full / Limited with description]
• External/adnexa: [Findings]
• Slit lamp anterior segment: Cornea [Findings]; AC depth/clarity [Findings]; Iris [Findings]; Lens [Findings]

Intraocular Pressure

• Time: [HH:MM]
• Method: [GAT / iCare / Tono-Pen / Other]
• OD: [mmHg] — [On drops / Untreated], [Pre-dilation / Post-dilation], [Reliability concerns if any]
• OS: [mmHg] — [On drops / Untreated], [Pre-dilation / Post-dilation], [Reliability concerns if any]

Pachymetry (CCT)

• OD: [micrometers]
• OS: [micrometers]
• Interpretation: [Thin / Average / Thick] — [Brief note on risk and tonometry interpretation considerations]

Gonioscopy

• OD: [Quadrant-by-quadrant: Shaffer grade and most posterior structure visible; pigmentation grade; PAS presence/extent; secondary signs]
• OS: [Quadrant-by-quadrant findings as above]

Summary: [One-line summary, e.g., "Open to scleral spur 360° OU, no PAS, moderate TM pigment."]

Dilated Fundus Exam

• Optic nerve/RNFL — OD: [Vertical C/D ratio; rim integrity with thinning/notching location; disc hemorrhage presence/location; disc size/tilt; peripapillary atrophy; visible RNFL defects]
• Optic nerve/RNFL — OS: [As above]
• Macula: [Pathology that could confound OCT or VF interpretation, or "Normal"]
• Vessels/Periphery: [Findings if clinically relevant]

Baseline Testing

(For each test, include metadata, reliability, key results, and clinician interpretation. If not performed, document "Not performed—[reason]" with plan.)

Visual Field

• Program/Device/Date: [24-2 / 30-2 / 10-2], [Device], [Date]
• Reliability — OD: [Fixation losses, false positives, false negatives, gaze tracking]
• Reliability — OS: [As above]
• Results — OD: [MD, PSD; pattern description]
• Results — OS: [As above]
• Interpretation: [Pattern/severity; structure–function agreement; baseline suitability or need for repeat]

OCT

• Scan types/Device/Date: [RNFL / ONH / Macular GCL], [Device], [Date]
• Signal strength/Artifacts: [Quality metrics and artifact notes]
• Results: [Quadrant/clock-hour RNFL thinning; ONH metrics; GCL thinning patterns]
• Interpretation: [Clinical interpretation; structure–function agreement; baseline suitability]

Optic Nerve Photography

• Photos obtained: [Yes — adequate / Yes — limited due to (reason) / No — plan to obtain]

Assessment

(Document each eye separately with eye-specific diagnosis, staging, and target IOP.)

OD

• Diagnosis: [POAG / Glaucoma suspect (ocular hypertension / suspicious disc-RNFL / suspicious VF) / Secondary open-angle glaucoma (mechanism) / Other]
• Stage: [Mild / Moderate / Severe / Indeterminate] — [Rationale: VF regions involved, structural-functional correlation] (Use "Indeterminate" when no reliable VF available.)
• Target IOP: [Target mmHg or percent reduction] based on [baseline reference IOP] — Rationale: [stage, age/life expectancy, CCT, fellow eye status, risk factors]
• Treatment threshold (if suspect): [Criteria for initiating treatment, e.g., confirmed progression or sustained IOP above X with high-risk features]

OS

• Diagnosis: [As above]
• Stage: [As above]
• Target IOP: [As above]
• Treatment threshold (if suspect): [As above]

Plan

(Organize by eye. Each element should be actionable and tied to documented findings and target IOP.)

OD

• Management: [Observation with monitoring plan / Initiate medical therapy / Laser (SLT) / Surgical referral]
• Medication (if starting): [Drug, concentration, eye, frequency; rationale; side effects reviewed; IOP check timing]
• Progression monitoring: [Criteria and triggers to escalate care]

OS

• Management: [As above]
• Medication (if starting): [As above]
• Progression monitoring: [As above]

Orders

• [Visual field: program and eyes]
• [OCT: scan types and eyes]
• [Optic nerve photos]
• [Deferred exam components]
• [Outside record requests]
• [Referrals]

Patient Education

• [Diagnosis/suspect status explained; chronic nature and follow-up importance discussed]
• [Medication technique and adherence counseling if starting therapy]
• [Informed refusal documented if patient declines recommendations, with risks reviewed]

Follow-up

• Interval: [Timeframe]
• Next visit: [Planned testing — VF/OCT/IOP check/gonioscopy/DFE/photos]
• Contingencies: [Instructions if symptoms worsen or medication side effects occur]