Optometry Diabetic Eye Examination Note

Patient: [name, DOB, MRN]

Date: [encounter date]

Provider: [name and credentials]

Visit Type: [screening / monitoring known retinopathy] [new / established]

Subjective

Reason for Visit: [chief complaint or screening indication] (One line; specify screening vs monitoring and include visual complaints if present.)

Diabetes History:

• [Diabetes type: Type 1 / Type 2 / Other / Unknown]
• [Duration since diagnosis in years / Unknown]
• [Most recent A1C with date / Unknown]
• [Current diabetes medications / Unknown]
• [Relevant comorbidities: hypertension, renal disease, pregnancy / Unknown]

(Document unavailable elements as "Unknown" rather than omitting.)

Ocular History: [Prior DR/DME diagnosis and treatment; prior ocular surgery; last dilated exam date]

Symptoms: [visual symptoms with onset, duration, laterality, and character] (If asymptomatic screening, document "Denies visual symptoms.")

Objective

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

IOP: OD: [mmHg] / OS: [mmHg] [method]

Anterior Segment: [pertinent findings; note cataract, NVI, or other diabetes-related findings if present]

Dilation: [agents used, time, adequacy] (If not dilated, document reason, alternative assessment method, and limitations.)

Posterior Segment:

• OD: [vitreous, optic nerve C/D, macula, vessels, periphery — pertinent findings]
• OS: [vitreous, optic nerve C/D, macula, vessels, periphery — pertinent findings]

Imaging/Testing: [test name, laterality, interpretation] (Include only if performed; otherwise omit this field.)

Assessment

(List diagnoses by threat to vision. DR stage and DME status must be explicitly documented for each eye. If view inadequate, document "Indeterminate" with limiting factor—never document "No DR" when view is limited.)

• OD
  • Diabetic Retinopathy: [No apparent DR / Mild NPDR / Moderate NPDR / Severe NPDR / PDR / Indeterminate—view limited by (reason)]
  • Diabetic Macular Edema: [Absent / Present—center-involving / Present—non-center-involving / Indeterminate]
• OS
  • Diabetic Retinopathy: [No apparent DR / Mild NPDR / Moderate NPDR / Severe NPDR / PDR / Indeterminate—view limited by (reason)]
  • Diabetic Macular Edema: [Absent / Present—center-involving / Present—non-center-involving / Indeterminate]
• Other Diagnoses: [cataract, glaucoma, other relevant findings] (Include only if applicable.)

Plan

• [Problem]: [monitoring plan, treatment, referral decision with laterality]
• [Additional problems as needed]

Follow-Up Interval: [interval with rationale] (No apparent DR: annual; Mild-Moderate NPDR: 6–12 months; Severe NPDR, PDR, or DME: prompt retina referral.)

Referrals: [specialty and urgency] (Omit if none.)

Patient Education: [counseling on screening importance, systemic control, and return precautions for floaters/flashes/sudden vision loss/field changes]

Communication to PCP/Endocrinology: [summary sent including DR stage per eye, DME status per eye, follow-up interval, and referrals] (Use non-technical language suitable for non–eye-care providers.)