YAG Posterior Capsulotomy Procedure Note

Nd:YAG Posterior Capsulotomy – Procedure Note

Procedure Logistics

Date/Time: [Procedure date and start time]

Location: [Clinic / Laser suite]

Proceduralist: [Name and credentials]

Eye: [OD / OS / Bilateral same-day] (Display prominently for laterality safety. For bilateral same-day, document each eye separately in Procedure Details.)

Procedure Summary

[Brief 4–6 line snapshot including: procedure performed, eye treated, diagnosis with laterality, one-line indication summarizing functional impairment or visualization need, and immediate outcome]

Indication & Medical Necessity

Symptoms and functional impact: [Patient-reported symptoms attributable to PCO and functional limitations] (Required: document specific functional impairment such as blurry vision, glare, halos, difficulty reading or driving; do not infer medical necessity from diagnosis alone. If missing from dictation, insert placeholder requiring completion.)

• Diagnosis: [Posterior capsule opacification – OD / OS]
• Objective findings: [BCVA; slit-lamp description of PCO density, location, and effect on visual axis]
• Alternate indication: [Need to improve posterior segment visualization for retinal or glaucoma management] (Only include if applicable.)

Pre-Procedure Status

• Baseline IOP: [Value and method] (If not obtained, document reason and mitigation plan.)
• Relevant ocular comorbidities: [Glaucoma / Uveitis history / High myopia / Prior retinal pathology / None]
• IOL status: [Well-centered and stable / Decentered / Other]

Consent & Verification

[Consent attestation stating informed consent obtained with discussion of risks including IOP elevation, inflammation, IOL pitting, cystoid macular edema, and retinal tear/detachment; benefits; and alternatives. Time-out performed confirming correct patient, procedure, and eye.] (Never infer consent from "patient tolerated" – must be explicitly documented.)

Peri-Procedure Medications

• Mydriatic drops: [Drug and concentration / None]
• Topical anesthesia: [Agent]
• IOP prophylaxis: [Drug and timing / None] (Document "none" rather than leaving blank.)
• Contact lens: [Type / None]

Procedure Details

Eye: [OD / OS]

• Technique: [Capsulotomy pattern and opening position]
• Laser parameters: [Energy per pulse in mJ]; [Number of shots]; [Total energy in mJ / Total energy not available from device]
• IOL pitting: [Yes / No]
• Adequate capsulotomy opening achieved: [Yes / No]
• Intra-procedure complications: [Description / None]

(For bilateral same-day procedures, duplicate the above subsection for each eye with separate parameters and complication documentation.)

Post-Procedure Status

• Tolerance: [Well tolerated / Description of tolerance issues]
• Post-procedure IOP: [Value] at [timing post-laser] (If not obtained, document reason and alternative plan.)
• Complications: [None / Type, timing, severity, management, and revised plan]

Post-Procedure Plan

• Medications: [Anti-inflammatory drop: drug, dose, frequency, duration]; [IOP-lowering medication if indicated: drug, dose, frequency, duration]
• Return precautions reviewed: [Yes – patient counseled on warning signs including flashes, new floaters, curtain or veil, severe pain, sudden vision loss]
• Follow-up: [Timeframe] (Specify earlier follow-up for high-risk patients with glaucoma, uveitis history, or prior retinal pathology.)
• Special justification: [Justification for capsulotomy within 3 months of cataract surgery or repeat capsulotomy on same eye] (Only include if applicable.)

Signature

[Electronic signature, credentials, date/time]