Optometry Contact Lens Follow-Up Note

Date/Time: [Date and time of encounter]

Patient: [Patient name and identifier]

Provider: [Provider name and credentials]

Encounter Type: [CL follow-up / CL problem visit]

Lens Modality: [soft spherical / toric / multifocal / RGP / scleral / ortho-K / other]

Lens Status at Arrival: [lenses in / removed]; (If removed, document time since last wear. If unknown, state "unknown" with reason.)

Chief Complaint

[Brief reason for visit or patient quote]

Subjective

• Vision/Comfort: [Distance vision, near vision if applicable, comfort level, end-of-day symptoms]
• Wearing Pattern: [Hours/day, days/week, overnight wear, naps with lenses]
• Current Lens Parameters: [Brand, BC, diameter, power, add/cylinder-axis if applicable, replacement schedule]; Verified from [packaging / EHR / patient report only]
• Care System: [Solution type, rub/rinse practice, case hygiene, case replacement frequency]
• Red-Flag Screen: Pain [endorsed / denied / not assessed]; Photophobia [endorsed / denied / not assessed]; Redness [endorsed / denied / not assessed]; Discharge [endorsed / denied / not assessed]; Decreased vision [endorsed / denied / not assessed]; Foreign body sensation [endorsed / denied / not assessed]
• Relevant History Updates: [Dry eye, allergies, medications affecting ocular surface, other pertinent updates] (Only include if explicitly mentioned.)
• Complication Details: [Onset, duration, time course, laterality, self-treatment attempted, last lens wear time] (Only include for problem visits.)

Objective

VA with CLs: OD [__] OS [__] OU [__]; Near [__] (if multifocal/monovision)

Over-refraction: [Sphere, cylinder x axis if performed]; Resulting VA [__] (Only include if performed.)

Lens Fit (in situ): Centration [__]; Movement on blink [__]; Surface condition [__]; (For torics: rotation and stability. For specialty lenses: relevant parameters such as vault or fluorescein pattern.) (If lenses not present, document "Fit assessment deferred—lenses not present.")

Ocular Health (slit lamp): Lids/lashes [__]; Conjunctiva [__]; Cornea [clarity, staining location/pattern/grade if present]; Tear film [__]; Anterior chamber [__] (if indicated)

Post-removal findings: [Changes observed after lens removal] (Only include if different from lens-on exam.)

Diagnostic agents: [Agent, lot, expiration] (Include per practice policy when used.)

Assessment

• Contact lens performance: [Laterality]; [new / stable / improving / worsening]; [Brief supporting evidence]
• Fit assessment: [Acceptable / Concerns noted]; [Laterality]; [new / stable / improving / worsening]
• Ocular surface findings: [Diagnosis with laterality and status]; [Brief evidence] (Only include if findings present.)
• Complication: [Diagnosis with laterality and status]; [Supporting objective findings] (Only include if complication present.)

Plan

• Lens Disposition: [Continue current / Modify parameters / Discontinue wear]; [Trial lens dispensed with parameters and wear-time instructions if applicable]; [Fitting status: complete / not complete with reason]; (If finalized, document final Rx and that prescription was released per FTC Contact Lens Rule.)
• Wear Schedule: [Daily wear / Extended wear permitted]; Max [__] hours/day; Replace every [__]
• Hygiene Counseling: Counseled on hand hygiene, no water exposure, no sleeping in lenses unless directed, no topping off solution, case replacement. [Patient verbalized understanding / Written instructions provided]
• Treatment: [Medications with dose/frequency, lid hygiene, rewetting drops as indicated] (Only include if treatment prescribed.)
• Follow-Up: Return in [__] for [__]; return sooner PRN for worsening
• Return Precautions: [Advised to remove lenses and seek urgent care for increasing pain, photophobia, decreased vision, increasing redness, or visible corneal opacity] (For routine visits without symptoms: "Standard care instructions reviewed.")

Signature

Provider: [Name, credentials, signature/date]

Scribe/Tech: [Name and role] (Only include if applicable.)