Exam forms/Electronic files

[Ryan_eyeball]

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I've found that I really disllike writing all the time freehand for charts. I'm considering just using a computer in the exam room like a laptop. I have a template that I would pretty much use on everybody and just modify it for the particular patient. This way already a lot of the peritent negatives are checked off.

Like or dislike, do you all prefer a free hand writing chart? Pictures drawn can be scanned in also.

 

[Ryan_eyeball]

last seen.

**************************************************

*OCULAR PROBLEM LIST/Ocular ROS

(previous year's assessment and plan)
**************************************************

Reason for the visit:

Here for a visual analysis

CC:


*HISTORY OF PRESENT ILLNESS*
Location: O.U.
Quality: Blurred Vision
Severity: Mild
Duration: yrs.
Timing:
Context: reading
Modifying factors: glasses
Assoc. signs & symptoms:
Eyestrain with reading without the glasses

Ocular ROS:
no surgery
no lasers
no injuries
no loss of vision
no double vision

Family OcHX:
no blindness
no glaucoma
no RD

ROS: no change from problem & medication lists


Problem list, medications and allergies reviewed:

|PROBLEM LIST (ACTIVE)|


Serology for Diabetes

|GLUCOSE|

|HBA1C|

If pt is Diabetic approx. what year was it diagnosed?


Neuro: Orientation nl
Psych: Mood/Affect nl


*VISUAL ACUITY*

Distance Visual Acuity

With correction

O.D. (current Spec Rx +1.00) 20/
O.S. (current Spec Rx +1.00) 20/


Pupils PERRLA (-) APD OU
Confrontation: FTFC OU
Extra-Ocular Muscles
Full and smooth OU
No diplopia
No restrictions
No palsy

Externals Eyelids/adnexa Unremarkable OU


Refraction (Date--fill in)

O.D. (today's Rx) 20/
O.S. (today's Rx) 20/

*SLIT LAMP EXAMINATION*
Lids/Lashes No blepharitis OU
Tears Normal
Conjunctiva No injection OU
Cornea No staining clear OU
Ant Chamber NO cells/flare deep & quiet OU
Iris No rubeosis- normal OU
Lens NS cataract OU
Media O.D. 20/
O.S. 20/

Intraocular Pressures (Goldmann) 1 gtt fluress

O.D.
O.S. Time:

RETINAL EVALUATION *****1 phenyleph 2.5%, 1 trop 1% OU
DFE Dilated retinal exam Time:

Optic Nerve

O.D. . CDR Flat, pink and discrete
O.S. . CDR Flat, pink and discrete

NO NVD/NVE

Vessels 2/3 OU
(-) hollenhorst plaques
(-) hemorrhages

NO evidence of Diabetic Retinopathy
NO CSME O.D.
NO CSME O.S.

Macula clear OU
(+) FR
NO evidence of CRNVM OU
(-)subretinal heme/(-)exudate(-)serous (-)Greenish gray

Periphery

O.D. No holes tears or detachments
O.S. No holes, tears or detachments

Vitreous No PVD OU

Assessment
1.
2.
3.
4.

Plan

1. Educated pt on findings
2. Answered all the pt. questions
3. New Spec Rx
4.
5.
6. RTC in 12 months or PRN for any problems





Rest is additional reports (if applicable)
**************************************************************

VISUAL FIELD Report

**************************************************************
HVF 24-2 Report

CLINICAL HISTORY:

O.D

Reliability good
Fixation losses
Foveal threshold
MD

Results/Impressions:
Full Visual field
(+) superior defect most likely due to lid

O.S.

Reliability good
Fixation losses
Foveal threshold
MD

Results/Impressions:
Full Visual field
(+) superior defect most likely due to lid


Comparison to previous field

Stable
Progressive (choose one, and give assessment below)

Assessment:




Gonioscopy

1 gtt of proparicaine/artificial tears

O.D. GR IV

CB
CB X CB (-) PAS
CB (-) Angle recession
(-) NVA
O.S. GR IV
CB
CB X CB (-) PAS
CB (-) Angle recession
(-) NVA


*********************************************************************

**************GLAUCOMA FLOW CHART*************************

Date OD OS HVF Gonio Photos Meds

*******************************************************************

 

[Ryan_eyeball]

Sorry my copy was more nicely spaced on microsoft word. Anything on the template can be modified for a particular patient/complaint/ or history.

 

[Schroder79]

We are going to electronic soon but right now I prefer freehand, but maybe that is just because technology isn't high enough yet. My handwriting is sometimes hard to read though and with Dr. Coopers program you can graph the refractive data and use the different comfort criterien, but I doubt many practicing doc's do that anyway. I think electronic records is a good idea though and it will get better.

 

[BKK]

Since I practice in a very large group practices in the world, with satellite offices/hospitals across the globe, the DoD Health care system, we use a new electronic medical system caled AHLTA. This system is still being deployed to new facilities and requires new users a bit of adjustment time for proficiency, but it is good system. It is great being able to view the patient information/past visits seen across the gloge on my office PC. The eyecare application is a bit rough and you have to get proficient at formatting a reasonable looking form, but it is legible and accessible by any clinic on AHLTA.


BKK