Optometry Problem-Focused Eye Visit Note (Urgent/Same-Day)

Header

• Date/Time: [Encounter date and time]
• Patient: [Patient name / identifier]
• Clinician: [Clinician name and role]
• Reason for Urgent/Same-Day Visit: [Patient-stated reason or referral source]

Chief Complaint

[Presenting symptom(s) in patient language] — [OD / OS / OU / laterality unclear] (Use verbatim phrasing when descriptive.)

Priority statement: [Sight-threatening conditions being ruled out] (Briefly note the key urgent diagnoses being considered.)

History

[Focused HPI in paragraph format covering: onset and timing; laterality; location (surface vs deep); current vision compared to baseline; pain and photophobia characteristics; relevant context including contact lens wear (type, hygiene, overnight use), trauma mechanism, chemical exposure, or foreign body risk; prior similar episodes; self-treatment attempted]

Pertinent Ocular History: [Prior ocular disease, surgeries, current ophthalmic medications]

Relevant Medical Conditions: [Diabetes / autoimmune disease / immunosuppression / other pertinent conditions]

Current Systemic Medications: [Medication list]

Allergies: [List with reaction type, or "NKDA"]

Safety-Critical Elements:

• Vision change: [present / absent / not assessed — reason]
• Severe pain: [present / absent / not assessed — reason]
• Photophobia: [present / absent / not assessed — reason]
• Recent trauma: [yes (mechanism/timing) / no / not assessed — reason]
• Contact lens wear: [yes (type, hygiene, overnight use) / no / not assessed — reason]
• Neurologic symptoms: [present / absent / not assessed — reason]
• Flashes/floaters with field loss: [present (characterize) / absent / not assessed — reason]

Examination

(Document OD and OS separately. If an element was not performed, state reason and plan.)

• Visual Acuity: OD: [VA sc/cc]; OS: [VA sc/cc]; Pinhole if reduced: [OD/OS result] (Method: [Snellen / near card / other])
• Pupils: [Size/reactivity OD/OS]; RAPD: [present / absent / unable to assess — reason]
• IOP: OD: [value] mmHg; OS: [value] mmHg; Method: [Goldmann / Tonopen / NCT] (If not measured, document reason and plan.)
• External/Lids: OD: [findings]; OS: [findings] (Include lid eversion if performed.)
• Conjunctiva/Sclera: OD: [findings]; OS: [findings]
• Cornea: OD: [findings]; OS: [findings] (Include fluorescein staining pattern and Seidel test if performed.)
• Anterior Chamber: OD: [depth, cells/flare]; OS: [depth, cells/flare]
• Iris: OD: [findings]; OS: [findings]
• Lens: OD: [findings]; OS: [findings]
• Posterior Segment: [undilated / dilated] — OD: [findings]; OS: [findings] (If dilation not performed, state reason and plan.)

Additional exam elements as indicated: [Confrontation fields, extraocular movements, preauricular nodes, color vision — include only if performed]

Deferred/Limited Elements: [Elements not performed, reasons, and plan to complete or refer]

Assessment

(List problems in descending urgency. Include laterality, working diagnosis or "undifferentiated," key supporting findings, do-not-miss differential, and risk statement when vision-threatening pathology not excluded.)

1. [OD / OS / OU] — [Working diagnosis or "Undifferentiated (symptom)"]: [Key supporting findings]. Differential includes [do-not-miss conditions]. [Risk statement if applicable — e.g., "Cannot exclude X without dilated exam."]

2. [OD / OS / OU] — [Working diagnosis]: [Key supporting findings]. Differential includes [do-not-miss conditions]. [Risk statement if applicable]

(Add additional problems as needed.)

Plan

(Address each problem with treatment details, restrictions, follow-up, and referrals.)

Problem 1: [Medication name, concentration, dose, frequency, duration]. [Restrictions: contact lens holiday / protective eyewear / activity limits as applicable]. Follow-up: [timing and rationale]. [Referral if indicated: service, urgency, communication method].

Problem 2: [Treatment, restrictions, follow-up, referral details as applicable].

Return Precautions Reviewed: [worsening pain / increased photophobia / decreased vision / new flashes or floaters / curtain, veil, or field loss / inability to use medications / fever or systemic symptoms — include precautions relevant to this patient's condition]. Patient verbalized understanding: [yes / no — if no, explain].

Procedure

(Include only if a procedure was performed.)

• Procedure: [Foreign body removal / Irrigation / Other]
• Indication: [Indication]
• Consent: [Verbal / Written] — risks and benefits discussed
• Technique: [Brief description]
• Findings: [Key findings]
• Complications: [None / Describe]
• Post-procedure instructions: [Instructions, medications, follow-up]