Postoperative Follow-Up Note (Cataract/Anterior Segment)

Date/Time: [Date and time of encounter]

Postoperative Timepoint: [POD1 / POW1 / POM1 with exact day count]

Laterality: [OD / OS]

Location: [Clinic or facility]

Clinician: [Examining clinician]

Visit Type: [Routine postoperative follow-up / Urgent postoperative evaluation]

Index Surgery

[Brief structured summary of index surgery] (Include procedure performed, date of surgery, surgeon, and intraoperative course—state "uncomplicated" or specify key complications such as posterior capsule rupture, vitreous loss, sulcus IOL placement, or sutures. Include IOL details when available: model, power, target refraction, placement location, and toric axis if applicable. If operative details are unavailable, explicitly state this rather than inferring.)

Interval History

[Narrative of patient-reported interval course] (Capture subjective vision assessment with trajectory and specific complaints; pain or discomfort level; presence or absence of photophobia, redness, discharge, flashes, floaters, or curtain symptoms. Document drop adherence including medications, frequency, and missed doses. Note compliance with protective measures and any trauma, rubbing, or water exposure since surgery.)

Objective

Visual Acuity: [Operative eye uncorrected and pinhole if reduced; manifest refraction at POM1 when appropriate; note method and limitations]

IOP: [Value, method] (Document pre- and post-intervention values if IOP-lowering or -raising intervention performed.)

Slit-Lamp Exam: [Cornea clarity, edema, epithelial status; incision/wound apposition and Seidel if concern; AC depth, cell and flare grade; iris/pupil shape and synechiae; IOL position and centration; posterior capsule status; anterior vitreous if complication history or clinical concern]

Posterior Segment: [Dilated fundus exam findings when indicated] (Include when symptoms suggest retinal pathology, unexplained decreased VA, or significant inflammation. If dilation deferred, state reason.)

Ancillary Testing: [OCT, topography, or other studies with brief interpretation] (Include only when obtained.)

Assessment

[Problem-oriented list in descending severity] (Each problem should state diagnosis or status with supporting findings from today's exam. Commonly includes: pseudophakia status with surgery date, postoperative inflammation grade, IOP status, wound integrity, corneal status, and any complications. When uncertainty exists, note the differential. Do not copy forward prior assessments without reconciling with today's findings. If a complication is suspected, include evaluation performed and escalation actions within relevant problem entries.)

Plan

Medications: [Changes made today—stops, starts, taper initiation] (Document with clear schedules and target stop dates. Avoid restating unchanged regimen unless needed for clarity.)

Precautions: [Emergency return precautions documented] (Instruct to seek prompt care for significant vision reduction, increasing pain, progressive redness, new floaters/flashes/curtain, or purulent discharge.)

Activity Guidance: [Shield duration and activity restrictions appropriate to timepoint]

Follow-Up: [Next visit timing and planned tasks such as refraction, dilation, suture removal, or IOP recheck]

Care Coordination: [Communication with co-managing provider or operating surgeon] (Include only when applicable.)