Optometry Cataract Post-Operative Follow-Up Note (Co-management)

Date/Time: [Encounter date and time]

Patient: [Patient full name and identifier]

Provider: [Co-managing provider name and credentials]

Procedure: cataract extraction with IOL

Eye: [OD / OS]

Surgery Date: [Surgery date]

Surgeon: [Surgeon name or "not available"]

Facility: [Surgical facility name]

IOL Details: [Model/power/toric axis or "not available"]

Transfer of Care: [assumed / shared / not transferred]

Date Assumed: [Date co-management assumed, if applicable]

Patient Consent Documented: [yes / no]

Chief Complaint

Post-op cataract surgery follow-up — [POD / POW / POM] [number] — [OD / OS]

Interval History

s/p cataract extraction with IOL on [surgery date] with [surgeon name or "not available"], presenting for routine follow-up with co-managing provider.

• Vision: [better / worse / same] [relevant details: distance vs near blur, glare/halos if present, onset/progression]
• Pain/Discomfort: [none / mild / moderate / severe] [location/character if present]
• Redness/Discharge: [present / absent] [description if present]
• Red-flag screening: Floaters [present / absent], Flashes [present / absent], Curtain/Shadow [present / absent]
• Current drop regimen: [Medication name, concentration, dosing frequency for each drop] (If patient unsure, document "patient unsure" and add action item to confirm with surgeon)
• Adherence: [good / fair / poor] [missed doses or technique issues if any]

Objective

• VA: [UCVA with method] [BCVA or pinhole if obtained, with correction used]
• IOP: [OD value, OS value] mmHg via [method] at [time]
• Anterior Segment: Conjunctiva [injection description]; Cornea [clarity/edema]; Wound [integrity/Seidel]; AC [depth, cell/flare grade]; IOL [position: centered/tilted/decentered]
• Posterior Segment: [DFE performed: findings by disc/macula/vessels/periphery] or [DFE deferred: reason] (Do not document normal posterior findings if dilation not performed)
• Imaging: [OCT/topography/other with one-sentence interpretation] (Only include if performed)

Assessment

• Pseudophakia [OD / OS] — [POD / POW / POM] [number]: [routine / complicated] post-operative course. [Brief clinical status summary]
• [Additional problems only if present: elevated IOP, persistent inflammation, corneal edema, CME concern, etc.] (Omit if none)

Plan

• Drops: [Continue / Adjust] [medication names with specific dosing/taper schedule]
• Activity: [Guidance per surgeon protocol, eye shield, precautions]
• Complication management: [Actions taken, escalation steps] (Only include if complications present)
• Surgeon coordination: [Notified: yes — method and content summary] or [Notified: no — routine findings, no contact required per protocol]
• Refraction: [Deferred: reason and planned timing] or [Performed: result and glasses plan]
• Follow-up: [Interval and milestone, e.g., POW1/POM1] [Return precautions for pain, vision loss, flashes/floaters/curtain]
• Action items: [Confirm drops with surgeon if patient unsure, obtain missing surgical details, schedule imaging/DFE as needed] (Include only if action items exist)