Retinal Laser Photocoagulation Procedure Note (PRP/Focal/Grid)
A procedure note template for retinal laser photocoagulation including PRP, focal, and grid techniques. Captures required laser parameters, treatment mapping, and safety documentation including time-out verification and…
Document Type
clinical note / Procedure Note
Specialties
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Procedure Date/Time: [Date and time of procedure]
Patient Name: [Patient full name]
MRN/DOB: [Medical record number] / [Date of birth]
Eye Treated: [Right / Left / Bilateral]
Procedure Type: [Panretinal Photocoagulation (PRP) / Focal Photocoagulation / Grid Photocoagulation / Combined Focal/Grid]
Proceduralist: [Clinician name and credentials]
Location: [Clinic/facility and room/device]
Indication
[Primary diagnosis with laterality] — [Clinical goal of treatment]
[Pertinent exam or imaging findings guiding treatment planning] (Summarize relevant findings such as neovascularization extent, OCT features, or fluorescein angiography results. Reference same-day clinic note for detailed findings if applicable. Omit if not assessed.)
Pre-Procedure
Informed consent obtained from [patient / surrogate (relationship)], including discussion of procedure, risks specific to the planned laser type, benefits, and alternatives; questions answered. Written consent signed: [Yes / No]
Pre-procedure time-out performed confirming correct patient, procedure, and eye.
- Positioning: [Seated at slit lamp / Supine for LIO / Supine for endolaser]
- Anesthesia: [Agent, concentration, and route] (Do not infer; omit if not documented.)
- Contact lens: [Lens type] with [coupling agent]
Procedure Details
(For bilateral procedures, complete a separate subsection for each eye.)
Right Eye (OD)
(Include only if right eye was treated.)
Laser Parameters
Laser Wavelength/Type: [e.g., 532 nm green / 577 nm yellow / Not recorded]
Delivery Mode: [Single-spot / Pattern (multispot) / Not recorded]
Spot Size: [Value in micrometers / Not recorded]
Pulse Duration: [Value in milliseconds / Not recorded]
Power: [Value or range in milliwatts / Not recorded]
Total Spot Count: [Number / Not recorded]
Pattern Type: [Pattern description / Not recorded] (Include only for pattern delivery.)
Spot Spacing: [Spacing description / Not recorded] (Include only for pattern delivery.)
(Do not infer parameters. If unknown, record "Not recorded.")
Treatment Location and Extent
[For PRP: quadrants or clock-hours treated; posterior boundary relative to arcades/macula; anterior extent toward equator; areas avoided or incompletely treated with reason]
[For focal/grid: technique used; anatomic location relative to fovea; confirmation that foveal center was avoided]
[Treatment adequacy, patient tolerance, visualization quality, and any deviations from planned treatment]
Complications
[None / Complication with severity and immediate management]
Post-Procedure Assessment
(Omit section if no post-procedure assessments were performed.)
- Gross vision: [Result]
- IOP: [Value and method]
Left Eye (OS)
(Include only if left eye was treated.)
Laser Parameters
Laser Wavelength/Type: [e.g., 532 nm green / 577 nm yellow / Not recorded]
Delivery Mode: [Single-spot / Pattern (multispot) / Not recorded]
Spot Size: [Value in micrometers / Not recorded]
Pulse Duration: [Value in milliseconds / Not recorded]
Power: [Value or range in milliwatts / Not recorded]
Total Spot Count: [Number / Not recorded]
Pattern Type: [Pattern description / Not recorded] (Include only for pattern delivery.)
Spot Spacing: [Spacing description / Not recorded] (Include only for pattern delivery.)
(Do not infer parameters. If unknown, record "Not recorded.")
Treatment Location and Extent
[For PRP: quadrants or clock-hours treated; posterior boundary relative to arcades/macula; anterior extent toward equator; areas avoided or incompletely treated with reason]
[For focal/grid: technique used; anatomic location relative to fovea; confirmation that foveal center was avoided]
[Treatment adequacy, patient tolerance, visualization quality, and any deviations from planned treatment]
Complications
[None / Complication with severity and immediate management]
Post-Procedure Assessment
(Omit section if no post-procedure assessments were performed.)
- Gross vision: [Result]
- IOP: [Value and method]
Follow-Up Plan
- Follow-up: [Interval or specific date]
- Additional laser sessions: [Planned sessions; for staged PRP, note session number]
- Imaging at follow-up: [OCT, fluorescein angiography, or none planned]
- Escalation criteria: [Indications for additional PRP, anti-VEGF, vitrectomy referral, etc.]
Electronic Signature: [Clinician name, credentials, date/time signed]
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