Entries removed from this example. Focus is on sections with eye-care content only.
| Patient | Legal: Clare M TESCA Date of Birth: October 22, 1962 (57yr) Gender: Female Patient-ID: 123456789 (SSN), 404.1 (1.3.6.1.4.1.115) |
| Encounter | ID: a5b48f7f-981c-480f-aa35-fb14a34e528e , Date/Time: March 6, 2020 10:30AM -0500 - 11:30AM -0500 |
| Documentation Of | Care provision, First postoperative examination and eye dressing (procedure), Date/Time: March 6, 2020 10:30AM -0500 - 11:30AM -0500, Performer: Stan STEDYHAN |
| Author | Dr Stan STEDYHAN, Organization: Stedyhan Ophthalmology, LLC, Authored On: March 6, 2020, 11:30AM -0500 |
| Encounter | Performer | Location | Encounter date | Diagnosis | Diagnosis Status |
|---|---|---|---|---|---|
| Post Op follow-up | Dr. Stan Stedyhan | 33 Front St.
Atlanta, GA 30308 |
March 06, 2020 | Normal vision | Active |
Uncorrected visual acuity on 2020-03-06 at 08:00a
| Method | Eye | Distance VA | Near VA | Pinhole |
|---|---|---|---|---|
| Snellen Chart | OD: | 20/80 | 20/40 | 20/20 |
| Snellen Chart | OS: | 20/100 | 20/30 | 20/25 |
| Snellen Chart | OU: | 20/80 | 20/30 |
Corrected visual acuity on 2020-03-06 at 08:00a
Aid to vision (Eye glasses)
| Method | Eye | Distance VA | Near VA | Pinhole |
|---|---|---|---|---|
| Snellen Chart | OD: | 20/20 | J1 | NIPH |
| Snellen Chart | OS: | 20/25 | J1+ | NIPH |
| Snellen Chart | OU: | 20/20 | J1+ |
Refraction measurements on 2020-03-06 at 08:15a
| Method | Eye | Usage | Sphere | Cylinder | Axis | H Prism | H Prism base | V Prism | V Prism base | Add | Distance VA | Near VA | Pinhole |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Manifest Refraction | OD: | Computer Glasses | -1.25 | -0.75 | 162 | 0.50 | BI | 0.75 | BU | +1.00 | 20/25-- | 20/20+ | 20/20-- |
| Manifest Refraction | OS: | Computer Glasses | -2.75 | -1.75 | 068 | 0.50 | BO | 0.75 | BD | +1.00 | 20/25-- | 20/20+ | 20/20-- |
| Manifest Refraction | OU: | 20/25-- | 20/20+ |
| Method | Eye | Usage | Sphere | Cylinder | Axis | H Prism | H Prism base | V Prism | V Prism base | Add | Distance VA | Near VA | Pinhole |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Autorefractor | OD: | Sunglasses | -1.25 | -0.75 | 070 | 0.50 | BI | 0.75 | BU | +1.00 | 20/25-- | 20/20+ | |
| Autorefractor | OS: | Sunglasses | -3.00 | -1.75 | 160 | 0.50 | BO | 0.75 | BD | +1.00 | 20/25-- | 20/20+ | |
| Autorefractor | OU: | 20/25-- | 20/20+ |
Tonometry (IOP)
| Method | Eye | Reading | Reference Range |
|---|---|---|---|
| NCT | OD: | 21 mm[Hg] | expected: 0 to 100 mm[Hg] |
| NCT | OS: | 18 mm[Hg] | expected: 0 to 100 mm[Hg] |
Dry eye tests
| Test | Method | Eye | Results | Reference Range |
|---|---|---|---|---|
| Osmolarity | Osmometer (720840007) | OD | 308 mOsm/L | expected: 0 to 400 mOsm/L |
| Osmolarity | Osmometer (720840007) | OS | 300 mOsm/L | expected: 0 to 400 mOsm/L |
| Schirmer | Filter paper (415500001) | OD | 15 mm | expected: 0 to 15 mm |
| Schirmer | Filter paper (415500001) | OS | 16 mm | expected: 0 to 15 mm |
| Tear Break-up Time (TBUT) | Sodium Fluorescein Dye (25351006) | OD | 11 seconds | expected: 0 to 15 seconds |
| Tear Break-up Time (TBUT) | Sodium Fluorescein Dye (25351006) | OS | 10 seconds | expected: 0 to 15 seconds |
| Tear Meniscus | Slit lamp photography of eye (16306001) | OD | 0.6 mm | |
| Tear Meniscus | Slit lamp photography of eye (16306001) | OS | 0.4 mm | |
| Assessment score | SPEED Questionnaire (273479001) | OU | 17 | expected: 0 to 28 |
Optic Disc
| Finding | Eye | Result |
|---|---|---|
| CD Ratio | OD: | Normal appearance with C/D ratio .3/.4 |
| CD Ratio | OS: | Normal appearance with C/D ratio .3/.3 |
Macula
| Finding | Eye | Result |
|---|---|---|
| Drusen | OD: | 2+ drusen throughout the posterior pole |
| Drusen | OS: | 1+ drusen throughout the posterior pole |
| Epiretinal membrane | OS: | Epiretinal membrane with macular thickening |
Posterior Retina
| Finding | Eye | Result |
|---|---|---|
| Cotton wool spots | OD: | Multiple cotton wool exudates superior temperal to the macula |
| Cotton wool spots | OS: | Multiple cotton wool exudates superior to the macula |
| Vessels | OS: | Nicking and banking of vasculature |
| Member | Role on Team | Status | Date |
|---|---|---|---|
| Dr. Joseph Gooddoc, MD (NPI: 2734441159 ) | Primary Care Physician | (Active) | 2005 - current |
| Maka Felgood | Diabetic Educator | (Active) | 2014 - current |
| Dr. Arthur Feetler, DPM (NPI: 8402871106) | Podiatrist | (Active) | 2018 - current |
| Dr. Donald Singletooth, DDS (NPI: 8477778822) | Dentist | (Active) | 1990 - current |
| Dr. Yul Seemore, OD (NPI: 1973535929) | Optometrist | (Active) | 2020 - current |
| Dr. Stan Stedyhan, MD (NPI: 2173512387) | Ophthalmologist | (Active) | 2020 - current |