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APD VA OD OS OU Hab. 20, Summaries of Nursing

Kishwaukee CollegeNursing

Symptoms: • Location: OD OS OU_________________________________________. • Quality: Blur Pain Tear Dry Itch Red. • Severity: Mild Mod Severe - Pain ___/10.

Typology: Summaries

2021/2022

Uploaded on 09/12/2022

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markzck 🇺🇸

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PATIENT: _______________________________________________ AGE: _______ DATE: ___________________
CC: ___________________________________________________________________________________ Dr. O’Daniel
Color Vision [ ] Yes [ ] No Stereopsis [ ]Yes [ ]No
Pupils PERRL
APD No Yes
V.F. Confrontations / FDT
Full OU defect OD / OS / OU
Tatum Dr O Exam 01-19-2018
VA
OD
OS
OU
Hab.
20/
20/
20/
w/o
20/
20/
20/
Near
20/
20/
20/
Symptoms:_________________________________________________
Location: OD OS OU_________________________________________
Quality: Blur Pain Tear Dry Itch Red ____________________________
Severity: Mild Mod Severe - Pain ___/10
Duration: _____ Day Week Month Year
Timing: Acute Constant Intermittent ___________________________
Context: Far Near Computer __________________________________
Modifiers: Drops / Glasses help __________________________________
Head/Face Normal
Mood/Affect (anxiety/agitation/depression) Normal
Oriented (person/time/place) Yes No
HabRx
C.T. Dist. Ortho Near NPC
Versions Smooth & Full OU restricted
K’s
Phorias
Near
Lateral
Dist.
Vertical
Auto
Near
NRA VA’S 20/
#7
PRA 20/
Ranges
Lids/Lashes clear OU Vitreous clear OU
Conj. clear OU Macula clear OU
Corneas clear OU Vessels clear OU
Lens clear OU ONH clear OU
Iris clear OU Periphery clear OU
A.C. clear OU
Angle. OD: 0 1 2 3 4 OS: 0 1 2 3 4 C/D OD______ OS______
OD ______ NCT Icare Goldman
Tonometry
OS ______ @ _______am / pm
Dilated OD OS OU Time: _____ am / pm
Procaine T 1/2% 1%
PE 2.5% Paremyd
Dermato____ NS____ AC____ PCO____ Dermato____ NS____ AC____ PCO____ Floaters____ PVD____ Floaters____ PVD____
Direct
78D
90 D
SF
20D
Photo
Pterygium___ Bleph___________ Bleph__________ Pterygium___
Arcus__ Arcus__
Ping__ Ping__
Cells___ Cells___ ___RPE Change___
Conj Inj ____ NaFl SPK____ TBUT___ Conj Inj ____ NaFl SPK____ TBUT___ Dry ARMD_____ Drusen____ Dry ARMD_____ Drusen____
IMPRESSION
1)
2)
3) Ocular Health Clear and Quiet OU
PLAN RTO: _____ day week month - 1 year default
1) Monitor Rx ______________________________________
2) Monitor Rx ______________________________________
3) Monitor Rx Refer _________________________________
4) Order - Photos OCT VF_______ ________
NOTES:
Myopia H52.1__ Astig H52.22__ Hyper H52.0__ Pres H52.4
NS H25.1__ DES H16.223 ARMD H35.3131 DM2 E11.9
Contact lens fitting – see CL fitting sheet
FINAL SPECTACLE RX: PD____/____
Add
OD______________________________
+ _____
OS ______________________________
+.25 PAL/Tri
Dr._____________________
[ ]O’Daniel [ ]Fuller [ ]McPhelan [ ]Felton
[ ] S0620 $120 [ ] S0621 $90 [ ] 92004 [ ] 92014 [ ] 92015 [ ]__________ [ ]__________ [ ]_________
New Estab New Estab
pf2

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PATIENT: _______________________________________________ AGE: _______ DATE: ___________________

CC : ___________________________________________________________________________________ Dr. O’Daniel

Color Vision [ ] Yes [ ] No Stereopsis [ ]Yes [ ]No

Pupils PERRL

APD No Yes

V.F. Confrontations / FDT Full OU defect OD / OS / OU

Tatum Dr O Exam 01-19-

VA OD OS OU

Hab. 20/^ 20/^ 20/

w/o 20/^ 20/^ 20/

Near 20/^ 20/^ 20/

Symptoms :_________________________________________________  Location : OD OS OU_________________________________________  Quality : Blur Pain Tear Dry Itch Red ____________________________  Severity : Mild Mod Severe - Pain ___/  Duration : _____ Day Week Month Year  Timing : Acute Constant Intermittent ___________________________  Context: Far Near Computer __________________________________Modifiers : Drops / Glasses help __________________________________  Head/Face Normal  Mood/Affect (anxiety/agitation/depression) Normal  Oriented (person/time/place) Yes No

HabRx OD 20/ Add+ C.T. Dist. O rtho Near NPC

OS 20/ bi / tri / pal Versions Smooth & Full OU restricted

K’s OD / @ S / D Phorias

Near

Lateral

Dist.

Vertical

OS / @ S / D Auto OD Near OS NRA VA’S 20/ #7 OD^^20 /^ Ph^ PRA^20 / OS 20 / Ph Ranges Lids/Lashes clear OU Vitreous clear OU Conj. clear OU Macula clear OU Corneas clear OU Vessels clear OU Lens clear OU ONH clear OU Iris clear OU Periphery clear OU A.C. clear OU Angle. OD: 0 1 2 3 4 OS: 0 1 2 3 4 C/D OD ______ OS ______

OD ______ NCT Icare Goldman Tonometry OS ______ @ _______am / pm

Dilated OD OS OU Time: _____ am / pm Procaine T 1/2% 1% PE 2.5% Paremyd

Dermato____ NS____ AC____ PCO ____ Dermato____ NS____ AC____ PCO ____ Floaters____ PVD____ Floaters____ PVD____

Direct 78D 90 D SF 20D Photo

Pterygium___ Bleph___________ Bleph__________ Pterygium___ Arcus__ Arcus__ Ping__ Ping__

Cells___ Cells___ ___ RPE Change___

Conj Inj ____ NaFl SPK ____ TBUT ___ Conj Inj ____ NaFl SPK ____ TBUT ___ Dry ARMD _____ Drusen____ Dry ARMD _____ Drusen____

IMPRESSION

Ocular Health Clear and Quiet OU

PLAN RTO : _____ day week month - 1 year default

1) Monitor Rx ______________________________________

2) Monitor Rx ______________________________________

3) Monitor Rx Refer _________________________________

4) Order - Photos OCT VF _______ ________

NOTES:

Myopia H52.1__ Astig H52.22__ Hyper H52.0__ Pres H52. NS H25.1__ DES H16.223 ARMD H35.3131 DM2 E11.

Contact lens fitting – see CL fitting sheet

FINAL SPECTACLE RX: PD ____/____

Add

OD______________________________

+ _____

OS ______________________________

+.25 PAL/Tri

Dr._____________________

[ ]O’Daniel [ ]Fuller [ ]McPhelan [ ]Felton

Mr.___ Mrs.___ Ms.___ Dr.___ Date ____/____/______

Last Name _______________________________ First ___________________________ Patient New / Previous

Address ______________________________________ City _______________________ Birth Date ____/____/______

State ______________ Zip ______________ Email ______________________________ Occupation __________________

Phone : Home _________________ Work _________________ Cell _________________ Last Eye Exam mo____/yr______

Vision Insurance _________________ ID# ________________ Medical Insurance ________________ ID# ________________

Primary Member’s Name __________________________ Primary’s Last 4 SSN _______ Primary’s Birth Date ____/____/____

Referred by: Family Friend Co-worker Insurance Drove by Internet Site ________________________

Do you have any allergies to medications? no yes If yes, explain: ___________________________________

List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):

______________________________________________________________________________________________

______________________________________________________________________________________________

IF YOU ARE A PREVIOUS PATIENT AND THERE ARE NO CHANGES IN YOUR OCULAR/MEDICAL OR FAMILY HISTORY YOU MAY CHECK THE APPROPRIATE BOX AND SKIP THAT SECTION. No change in Ocular Medical History No change in Family History

PATIENT’S OCULAR/ MEDICAL HISTORY

Last Medical Exam ____/____/______ Medical Dr’s Name _____________________

List all major injuries, surgeries and/or hospitalizations you have had___________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury: ________________________________________________________________________ Are you pregnant and/or nursing? no yes Do you wear glasses? no yes If yes, how old is your present pair of glasses? _____________

Do you wear contact lenses? no yes If yes, what is the brand and power? _____________________

Are they comfortable? no yes How often do you replace them? ________________________

Please check any conditions that you have or have had in the past: Loss of Vision Dryness Burning Chronic Infection of Eye/Lid Blurred Vision Mucous Discharge Foreign Body Sensation Styes or Chalazions Distorted Vision/Halos Redness Excess Tearing/Watering Flashes/Floaters in Vision Loss of Side Vision Sandy or Gritty Feeling Glare/Light Sensitivity Tired Eyes Double Vision Itching Eye Pain or Soreness Other__________________

FAMILY HISTORY

Please check any conditions that apply to your immediate family members:

Blindness Macular Degeneration Cancer Kidney Disease Cataract Retinal Detachment Diabetes Lupus Crossed Eyes Retinal Disease Heart Disease Thyroid Disease Glaucoma Arthritis High Blood Pressure Other__________________

NOTICE OF PRIVACY

Acknowledgement of Receipt of Privacy Notice

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law designated to protect the privacy of your health information. We understand that the information about you and your health is personal and our doctors and staff are committed to protecting the privacy of that information. Because of this commitment, we must obtain your special authorization before we may use or disclose your protected health information to any party. This office will only use and disclose necessary personal health information to permit the office to perform its administrative duties, provide eye care services, process vision benefit claims, or mail exam recalls. By signing below, I acknowledge that I have read/received the copy of the Notice of Privacy Practices for review.

Patient Signature _______________________________