Ophthalmology Consultation Note (Inpatient/ED)

Note type: Ophthalmology Consultation Note

Date and time of evaluation: [Date and time of evaluation]

Location: [Location (ED, inpatient unit, room/bed)]

Requesting service and provider: [Requesting service and provider; callback contact]

Consulting ophthalmologist: [Consulting ophthalmologist, credentials]

Reason for consult: [Reason for consult]

Urgency: [emergent / urgent / routine]

Consult Question

[Clinical question and decision needed today] (Use 1–3 concise sentences or brief bullets; reflect requesting team's wording when available. State whether ophthalmology agrees with the stated urgency.)

History

[Limitations to history and information sources, if applicable] (Begin with barriers such as altered mental status, intubation, language barrier, or non-cooperation; specify sources: patient, family, EMS, chart. Omit if history is obtained directly from patient without limitation.)

[Chief complaint and HPI narrative] (Include laterality [OD/OS/OU], onset and timing including last known normal for acute vision loss or trauma; pain and photophobia; character of vision change; associated ocular symptoms; relevant systemic symptoms. For trauma, include mechanism, velocity, material, and eye protection. For chemical exposure, include agent, time of exposure, and irrigation details. Include pertinent negatives that narrow the differential.)

[Relevant ocular history] (Prior diagnoses, surgeries/procedures, contact lens use and habits, baseline visual function.)

[Focused medical history] (Include conditions relevant to the consult such as diabetes, hypertension, vascular disease, autoimmune conditions, immunosuppression, anticoagulation.)

Medications: [Current ocular medications with dosing; relevant systemic medications]

Allergies: [Allergies pertinent to ophthalmic care]

Examination

(Document findings for each eye separately using OD/OS designation with numeric values and methods where applicable. If a core element cannot be assessed, document "not assessed" with the reason—do not imply normality for elements not examined.)

• Visual Acuity: OD [acuity, method]; OS [acuity, method] (Use CF/HM/LP/NLP notation for severely reduced vision; if not obtainable, state the reason.)
• Pupils: OD [size, shape, reactivity]; OS [size, shape, reactivity]. RAPD: [present / absent / unable to assess]
• Intraocular Pressure: OD [value] mmHg; OS [value] mmHg. Method: [applanation / Tono-Pen / iCare / palpation]. Time: [time]. (If deferred, state the reason.)
• Extraocular Movements: Versions [full / restricted]; Ductions [full / restricted]; Pain with movement [yes / no]; Diplopia [yes / no]; Nystagmus [present / absent] (Describe any abnormalities.)
• External/Orbital: [Lids, periorbital swelling, proptosis, resistance to retropulsion, orbital rim integrity, facial sensation] (Include when relevant to consult question.)
• Anterior Segment: OD: Conjunctiva [findings]; Sclera [findings]; Cornea [clarity, epithelial defect, infiltrate, fluorescein uptake]; Anterior chamber [depth, cells, flare, hyphema, hypopyon]; Iris [findings]; Lens [findings]. OS: Conjunctiva [findings]; Sclera [findings]; Cornea [findings]; Anterior chamber [findings]; Iris [findings]; Lens [findings]. Seidel test: [positive / negative / not performed]
• Posterior Segment: Dilation status: [dilated with (agent) at (time) / not dilated (reason)]. OD: Optic nerve [findings]; Macula [findings]; Vessels [findings]; Peripheral retina [findings]; Vitreous [findings]. OS: Optic nerve [findings]; Macula [findings]; Vessels [findings]; Peripheral retina [findings]; Vitreous [findings]. (If fundus not examined or view limited, state the reason.)
• Neuro-ophthalmic elements: [Color vision, red desaturation, confrontation visual fields, relevant cranial nerve findings] (Include when indicated.)

Ancillary Data Reviewed

[Imaging and labs reviewed with brief relevant findings] (Specify whether images were personally reviewed versus report only. Include CT orbit/head, MRI/MRA, ocular ultrasound, and relevant labs. Omit this section if no ancillary data is relevant.)

Assessment

[Direct answer to consult question] (State the working diagnosis with laterality, whether the condition is vision-threatening, and the urgency of intervention needed.)

1. [Problem 1]: [Diagnosis with laterality] — [Key supporting findings; differential diagnosis if uncertain; risk stratification: vision-threatening vs non-vision-threatening; immediacy of intervention]
2. [Problem 2]: [Diagnosis with laterality] — [Supporting findings, risk stratification] (Include additional problems as applicable.)

Recommendations

1. [Problem 1]:
   • Treatment: [Medication with generic name, formulation, dose, route, frequency, duration; specify laterality for topical agents; indicate timing: start immediately vs can await outpatient; include non-pharmacologic measures as applicable]
   • Diagnostics: [Additional imaging or labs with rationale; monitoring requirements with frequency]
   • Disposition and Follow-up: [Admission / observation / discharge]; Follow-up: [timing, location, visit components]. (If urgent OR/procedure is needed, document time-criticality and who was notified.)
   • Additional Consultations: [Service, reason, urgency] (Include if applicable.)
   • Return Precautions: [Specific symptoms prompting return or escalation] — Communicated to [patient / primary team / both].
2. [Problem 2]: [Structured recommendations as above] (Include additional problems as applicable.)

Communication

[Verbal communication with primary team: name, role, time, key recommendations conveyed] (For emergent findings, document immediate escalation. If recommendations were communicated via EHR only, note this and instruct the team to contact ophthalmology for any change or worsening.)