Documenting an ophthalmology list
aurii drafts the operation note, the day-one review and the letters back to the referrer.
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Spoken at the day-one review
The morning after a cataract list, in the rooms, on a synthetic patient.
"Day one after the right cataract, comfortable overnight, drops taken as written."
"Unaided six nine on the right, six six through the pinhole, and the left is six twelve."
"Cornea clear, mild cell in the anterior chamber, lens central in the bag."
"Pressure fourteen right, sixteen left, wound sealed with no leak."
"Chloramphenicol four times a day for a week, prednisolone acetate four times a day, down one drop a week."
"Second eye in four weeks, biometry is done, and letters to her optometrist and her GP today."
Day 1 after right phacoemulsification with intraocular lens. Comfortable overnight, drops taken as prescribed. Unaided acuity 6/9 right, 6/6 with pinhole. Left 6/12 in current spectacles.
Cornea clear. Mild anterior chamber cell. Intraocular lens central within the capsular bag. Intraocular pressure 14 right, 16 left. Wound sealed, no leak on slit lamp.
Chloramphenicol four times daily for one week. Prednisolone acetate four times daily, reducing by one drop each week.
- Second eye listed at four weeks, biometry already recorded
- Letters to the referring optometrist and the GP today
- Refraction in the rooms once the drops finish
Illustration of the drafting view.
The list, then the taper
aurii drafts the theatre note from what is spoken at each case, naming the eye, the anaesthetic and the lens with its power and model, and the day-one review note from the slit lamp findings and the pressures. The letters back to the optometrist and the GP draft from the same record. The surgeon signs each.
Documents from one review
Billing items are captured at the bedside against the episode, for your practice to claim. Billing.
Starter templates an eye list uses
An eye service works from the general starter set: the generic procedure note for theatre, the progress note for the day-one review, and the follow-up reminder for refraction.
Your letterhead and section order, set once, on every draft. The template set.
Correspondence back to the referrer
The letter to the optometrist carries the lens implanted, the taper dates and the refraction date. The GP receives the same account in shorter form. Both draft from the record and the surgeon signs both.
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