Glaucoma Follow-Up Note

Date/Time: [date and time]

Patient: [patient name / MRN]

Provider: [provider name, credentials]

Diagnosis: [glaucoma type, laterality, stage]

Target IOP: OD: [target value and basis] / OS: [target value and basis]

Interval History

[Reason for today's visit (routine monitoring / IOP check after medication change / concern for progression / other); interval symptoms (vision changes, discomfort, halos); acute events or steroid exposure since last visit] (Write as a concise 2–3 sentence paragraph.)

Medication adherence and tolerability: [What patient is actually taking; frequency of missed doses; barriers (cost, dexterity, confusion); direct quotes clarifying patterns; ocular surface symptoms; systemic side effects] (If not assessed, state exactly: "Not assessed today.")

Current Glaucoma Medications

• [Medication name, concentration — dosing frequency — eye(s)] (List each medication on a separate line.)

Last dose time: [time, if relevant for IOP interpretation] (Include only if timing impacts interpretation; otherwise omit.)

Allergies/Intolerances: [pertinent allergies or intolerances with reaction type] (If none, state "None known"; if unavailable, state "Not on file.")

Examination & Diagnostics

Visual Acuity: OD [VA] / OS [VA] [with correction status]

IOP: OD [value] / OS [value] — [method] at [time]

Anterior Segment: [pertinent findings]

Gonioscopy: [current angle status, or note prior status and date if unchanged] (Include only if performed or clinically relevant.)

Optic Nerve (ONH): OD: [rim character, notching, disc hemorrhage present/absent, C/D ratio]; OS: [rim character, notching, disc hemorrhage present/absent, C/D ratio]; [asymmetry if present] (Document more than C/D ratio to satisfy annual ONH evaluation.)

Dilation status: [dilated / not dilated] (If not dilated, state reason.)

Visual Field: [date], [eye(s)], [reliability/quality], [key indices/defect pattern], [comparison to prior], [interpretation: stable / possible progression / confirmed progression], [structure–function correlation] (Include only if reviewed today.)

OCT (RNFL/GCIPL): [date], [eye(s)], [quality], [key values], [comparison to prior], [interpretation: stable / possible progression / confirmed progression], [structure–function correlation] (Include only if reviewed today.)

Assessment

(Organize by eye. Do not state "stable" or "progressing" without citing supporting evidence.)

OD

IOP control: [at target / above target / below target]; [adequate / borderline / inadequate] — [supporting data]. Progression: [stable / possible progression / confirmed progression] — [cite evidence: ONH exam, VF, OCT findings]. [Risk modifiers (advanced stage, disc hemorrhage, monocular status) if relevant; uncertainty and plan to resolve if data conflict.] (Omit risk modifiers and uncertainty lines if not applicable.)

OS

IOP control: [at target / above target / below target]; [adequate / borderline / inadequate] — [supporting data]. Progression: [stable / possible progression / confirmed progression] — [cite evidence]. [Risk modifiers if relevant; uncertainty and plan to resolve if data conflict.] (Omit risk modifiers and uncertainty lines if not applicable. Use OU format only if findings and management are symmetric.)

Plan

Therapy: [continue current regimen / modify / escalate] — [medication changes with drug, dose, eye(s), counseling provided; or procedure discussion (SLT, surgery) and patient preference]

Adherence/Technique: [counseling or technique review provided] (Include only if performed.)

Testing: [next VF and/or OCT with rationale]

Follow-up: [interval and purpose] (Shorten interval if IOP uncontrolled or progression suspected; document rationale if extending beyond routine interval.)

Coordination: [communication to referring provider/PCP] (Include only if applicable.)