Ophthalmology Consult

Finished note

Example — generated by Notat from a sample visit

Reason for consultation:
Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope.

Assessment:
Stable clinical presentation requiring further outpatient evaluation.

Plan:
Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Ophthalmology Consult Note

[Date and time if mentioned]

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
(Structure symptoms and associated information into distinct paragraphs. Use full sentences and formal clinical language. Include onset, duration, laterality, associated symptoms, prior treatments, and relevant exposures.)

Past Ocular History:
(hyphenated list)
- [Previous eye conditions, surgeries, or trauma]
- [Use "None" if not applicable]

Past Medical History:
(hyphenated list)
- [Chronic illnesses, relevant systemic diseases]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- (Include both ocular and systemic medications)

Allergies:
(hyphenated list)
- [eg. No known drug allergies (NKDA)]

Family History:
(hyphenated list)
- [Ocular and systemic diseases in family members]

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]

Review of Systems:
(hyphenated list)
- [Pertinent positives and negatives, especially visual, neurological, and systemic symptoms]

Ophthalmic Examination:
(hyphenated list)
- [Vital signs if relevant]
- Visual Acuity: [OD: #, OS: #, with/without correction]
- Pupils: [Size, reactivity, RAPD]
- Extraocular Movements: [Full/restricted, pain]
- Intraocular Pressure: [OD: # mmHg, OS: # mmHg, method]
- Confrontation Visual Fields: [Findings]
- External Exam: [Lids, lashes, adnexa]
- Anterior Segment: [Conjunctiva, cornea, anterior chamber, iris, lens]
- Posterior Segment: [Vitreous, optic nerve, macula, vessels, periphery]
- Other relevant findings: [e.g., color vision, Amsler grid, special tests]

Investigations:
(hyphenated list)
- [Completed imaging, labs, or ancillary tests with results and units]
- [Pending or planned investigations should be listed under Assessment & Plan]

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary ophthalmic diagnosis]

#) [Diagnosis or problem as a numbered item]
(Hyphenated list with each corresponding plan item on a new line)
- [Further investigations]
- [Treatment] 
- [Referrals] 
- [Patient education]
- [Follow-up plan]