Ophthalmology Office Visit Note (Comprehensive)

Date: [Encounter date]

Patient: [Name, DOB, MRN]

Provider: [Rendering clinician; supervising clinician if applicable]

Visit Type: [new / established]; [problem-focused / comprehensive / postop / preop]

Chief Complaint

[Primary complaint with laterality (OD/OS/OU) when relevant] (For follow-up visits, include condition and interval. For routine screening without symptoms, state the reason. If not obtained, document why.)

History

[History of present illness] (Paragraph format. Explicitly state laterality, onset, duration, course, symptom characterization, severity, functional impact, and context. Document prior treatments and response. Include a brief patient quote if it clarifies the experience. For post-op visits, include post-op day/week, drop adherence, and new symptoms. For chronic disease follow-up, note interval changes and adherence. If details are unknown, state as such with context.)

• Ocular History: [OD: pertinent diagnoses, surgeries with dates, trauma] [OS: pertinent diagnoses, surgeries with dates, trauma] (Omit if not relevant to today's visit.)
• Medications: [Current ocular medications with dosing by eye; relevant systemic medications] (If medication reconciliation not performed, state this explicitly rather than listing potentially outdated information.)
• Allergies: [Drug allergies with reactions, or "NKDA" if verified]
• Pertinent Medical/Family/Social History: [Relevant conditions and risk factors impacting today's visit] (Omit non-pertinent items.)

(For narrow follow-ups with no changes, "Ocular and medical history reviewed; no interval changes" is acceptable.)

Examination

(Structure all eye-specific findings by OD/OS. Use explicit status terms such as "Deferred," "Not performed," or "Unable [reason]" when omission is clinically meaningful.)

Visual Acuity:

• OD: [Distance VA with correction status sc/cc/PH; near VA if relevant]
• OS: [Distance VA with correction status sc/cc/PH; near VA if relevant]

Pupils:

• OD: [Size, reactivity, APD present/absent]
• OS: [Size, reactivity, APD present/absent]

IOP: [Method, time if relevant]

• OD: [mmHg] (If not measured, state reason.)
• OS: [mmHg] (If not measured, state reason.)

External/Adnexa:

• OD: [Lids, lashes, lacrimal, orbit as relevant]
• OS: [Lids, lashes, lacrimal, orbit as relevant]

Anterior Segment:

• OD: [Conjunctiva, cornea, anterior chamber, iris, lens; note staining if performed]
• OS: [Conjunctiva, cornea, anterior chamber, iris, lens; note staining if performed]

Posterior Segment:

• OD: [Vitreous, optic nerve with C/D ratio, macula, vessels, periphery]
• OS: [Vitreous, optic nerve with C/D ratio, macula, vessels, periphery]

Dilation Status: [dilated / undilated / deferred] (If dilated, include agents and time. If not dilated, state reason. If patient refused, document counseling provided.)

Additional Testing: (Include only if performed or reviewed today.)

• [Test name with laterality: key findings, reliability if applicable, comparison to prior, and brief interpretation] (Repeat for each test performed, e.g., motility, confrontation fields, gonioscopy, OCT, HVF, fundus photos.)

Assessment

(List diagnoses by urgency or vision risk. Include differential diagnosis when uncertainty affects management.)

[Problem 1]: [Diagnosis with laterality (OD/OS/OU); stage/severity if applicable] — [new / stable / worsening / resolved / post-op]. [Brief rationale citing key findings from exam or testing.]

[Problem 2]: [Diagnosis with laterality; stage/severity if applicable] — [Status]. [Brief rationale.] (Repeat as needed.)

Plan

(Organize by problem. Specify eye, dose, and frequency for all ocular medications. Do not infer that orders were placed, counseling occurred, or consent was obtained unless explicitly documented.)

• [Problem 1]:
  • Treatment: [Medication name, concentration, OD/OS/OU, frequency, duration; procedures performed/planned; non-pharmacologic instructions]
  • Diagnostics: [Tests ordered with laterality and indication]
  • Counseling: [Risks, benefits, alternatives discussed; adherence and technique reviewed]
  • Referrals: [Consults, coordination with other providers]
  • Follow-up: [Interval and purpose]
  • Return Precautions: [Specific symptoms requiring urgent evaluation]
• [Problem 2]: (Repeat structure as needed.)

Refraction

(Include this section only if refraction was performed.)

Manifest Refraction:

• OD: [Sphere / Cylinder x Axis; Add if applicable] → [Resulting VA]
• OS: [Sphere / Cylinder x Axis; Add if applicable] → [Resulting VA]

Final Spectacle Rx: [OD/OS values, PD if relevant] (Include only if prescribed.)

Contact Lens: [Parameters OD/OS; fit assessment; wear schedule; care instructions] (Include only if applicable.)