Optometry Intermediate Eye Exam Note (Established Patient)

Date of Service: [date]

Patient: [name, DOB, MRN]

Clinician: [name, credentials]

Encounter Type: Established patient – problem-oriented intermediate eye exam

Source of History: [patient / caregiver / medical records] (Note interpreter use or history limitations if applicable)

Chief Complaint

[Primary concern with laterality (OD/OS/OU), ideally in patient words] (Single sentence; if multiple concerns, list primary then secondary briefly)

History

[History of present illness as narrative: onset, duration, course, laterality, quality/severity, aggravating/relieving factors, treatments attempted with response, pertinent associated symptoms, and relevant negatives influencing the differential. For established patients, compare to prior episodes or baseline when relevant.]

Pertinent Ocular History: [prior diagnoses, surgeries, trauma, contact lens wear as relevant] (Include only if relevant to presenting problem)

Pertinent Systemic History: [diabetes, hypertension, autoimmune disease, other conditions affecting eye care] (Include only if relevant)

Current Ocular Medications: [medication, concentration, dosing, laterality, adherence] (Include only if applicable)

Drug Allergies: [allergies/adverse reactions]

Examination

(Document only what was actually performed. Use OD/OS/OU notation throughout. If an expected element was not assessed, state why.)

Visual Acuity: [distance and/or near acuity with correction status (sc/cc); pinhole if indicated; baseline comparison if vision is the complaint]

Pupils: [size, reactivity, APD assessment]

Extraocular Movements: [full / restricted; relevant findings]

External/Anterior Segment: [lids/lashes, conjunctiva, cornea, anterior chamber with cells/flare if inflammation concern, iris, lens—pertinent positives and negatives]

IOP: OD [value] mmHg; OS [value] mmHg ([method]; time: [time]) (Include only if measured)

Posterior Segment ([dilated / undilated / deferred—if dilated, note agents; if deferred, note rationale]): [vitreous, optic disc with C/D ratio, macula, vessels, periphery—pertinent findings only]

Diagnostic Testing: (Include only tests performed today; document as identifiable test report)

• [Test name] ([OD / OS / OU]): Indication: [clinical reason]. Findings: [objective results]. Interpretation: [clinical meaning]. Comparison: [stable / improved / worsened / no prior]. Management impact: [how results affect plan]. (Note reliability concerns only if applicable)

Assessment

(Problem-oriented list ordered by clinical severity)

1. [Diagnosis with laterality (OD/OS/OU)]: [new / recurrent / stable / worsening / improved]. [Key supporting findings from history, exam, and testing]. [Brief differential if diagnostic uncertainty exists].

2. [Additional diagnosis with laterality]: [status and supporting findings] (Include additional problems only if addressed today)

MDM Summary (Include only if selecting E/M level): [Number/complexity of problems addressed; data reviewed, ordered, or independently interpreted; risk level from management decisions]

Plan

(Mirror assessment numbering)

1. [Problem]: [Treatment with complete prescribing details: drug, concentration, route, dose, frequency, duration, laterality, refills]. [Additional testing or referrals with urgency]. [Follow-up interval]. [Return precautions: symptoms requiring urgent evaluation]. [Patient education/counseling as relevant].

2. [Problem]: [Repeat plan elements as above] (Include only if additional problems addressed)

Clinician Signature: [electronic signature with date/time]