bilateral

SampleHistoryandPhysicalNoteChartingPlus™-ElectronicMedicalRecords

NoteforJohnDoeon6/6/02-Chart1124

ChiefComplaint:This26yearoldmaleprentstodayforacompleteeyeexamination.

Allergies:Patientadmitsallergiestoaspirinresultingindisorientation,GIupt.

MedicationHistory:Patientiscurrentlytakingamoxicillin-clavulanate125mg-31.25mgtablet,

lPractitionerMD,Adrenocot0.5mgtablet

lPractitionerMD,Vioxx12.5mgtablet(BID).

PMH:Pastmedicalhistoryisunremarkable.

PastSurgicalHistory:Patientadmitspastsurgicalhistoryof(+)appendectomyin1989.

SocialHistory:tdeniesSTD

tdeniestobaccou.

FamilyHistory:Unremarkable.

ReviewofSystems:Eyes:(-)dryeyes(-)eyeorvisionproblems(-)blurredvisionConstitutional

Symptoms:(-)constitutionalsymptomssuchasfever,headache,naua,dizzinessMusculoskeletal:

(-)jointormusculoskeletalsymptoms

EyeExam:Patientisapleasant,26yearoldmaleinnoapparentdistresswholookshisgivenage,is

welldevelopedandnourishedwithgoodattentiontohygieneandbodyhabitus.

VisualAcuity:

Visualacuity-uncorrected:OD:20/10OS:20/10OU:20/15

Refraction:

Lens-final:

OD:+0.50+1.50X125Prism1.75

OS:+6.00+3.50X125Prism4.00BASEINFresnel

Add:OD:+1.00OS:+1.00

OU:FarVA20/25

Pupils:Pupilexamrevealsroundandequallyreactivetolightandaccommodation.

Motility:Ocularmotilityexamrevealsgrossorthotropiawithfullductionsandversionsbilateral.

VisualFields:ConfrontationVFexamrevealsfulltofingerconfrontationOU.

IOP:IOPMethod:applanationtonometryOD:10mmHgMedications:Alphagan;0.2%Condition:

improving.

Keratometry:

OD:K135.875K235.875

OS:K135.875K241.875

Lids/Orbit:raleyelidsrevealswhiteand

quiet.

SlitLamp:isclearand

lendotheliumissmoothandofnormalappearance.

AnteriorSegment:Bilateralanteriorchambersrevealnocellsorflarewithdeepchamber.

Lens:Bilaterallensrevealstransparentlensthatisinnormalposition.

PosteriorSegment:ralretinasrevealnormalcolor,

contour,andcupping.

Retina:Bilatralretinas

revealnormalreflexandcolor.

TestResults:Noteststoreportatthistime

Impression:Eyeandvisionexamnormal.

Plan:Returntoclinicin12month(s).

PatientInstructions:

Patientwasgivenverbalandwritteninstructionsregardingeyecarefollowingpupildilation.

__________________________________lmologist,MD

SampleReferralLetterChartingPlus™-ElectronicMedicalRecords

6/6/02

MarcusWelby,M.D.

12318thStreet,Suite222

WestDesMoines,IA50265

:

JohnDoewaseninmyofficeinconsultationasrequestedbyyouasanewpatient

lowingisasummaryofmyfindingsand

recommendations:

Impression:Eyeandvisionexamnormal.

Plan:Returntoclinicin12month(s).

IfImaybeofanyfurtherassistanceinthecareofyourpatient,plealetmeknow.

Thankyouforprovidingmetheopportunitytoparticipateinthecareofyourpatients.

Sincerely,

lmologist,MD

SamplePrescriptionChartingPlus™-ElectronicMedicalRecords

lmologist,MD

DEA#:

_________________________________________________________

Name:JohnJDoeDate:6/6/02

OD:+0.50+1.50X125Prism1.75

OS:+6.00+3.50X125Prism4.00BASEINFresnel

Add:OD:+1.00OS:+1.00

Dr._____________________________________________

SampleBillingStatementChartingPlus™-ElectronicMedicalRecords

BillingStatement-Thursday,June06,2002

Provider:lmologist,MD

Patient:JohnJDoe,Chart1124

eSt.

JeryCity,NJ07040

Diagnos

1.V72.0ExaminationOfEyesAndVision

Treatments

t-15min.

RelatedDiagnos:V72.0

Modifiers:

Units:

ReferringPhysician:lPractitioner,MD

DateLastSeen:07/26/2001

SamplePatientInstructionsChartingPlus™-ElectronicMedicalRecords

PatientInstructionsforJohnDoeon6/6/02

YOUREYESHAVEBEENDILATED

tsusaccuratelyinvestigate

onofyoureyesisa

temporaryinconvenience;however,benefitsfaroutweightheinconvenience.

callytakesTWOtoSIX

thistime,readingmaybemoredifficultand

orttime,usif

youfeelyo

patienceduringthisveryimportantprocedureisappreciated!

CALLMYOFFICEIMMEDIATELYAT515-327-8850IFYOUEXPERIENCEEXCESSIVE

PAIN,DISCOMFORTORNAUSEA

REMEMBERTOHAVEREGULARMEDICALEYEEXAMINATIONS.

ostblindnessispreventableifdiagnodand

treatedearly,mindthat

manyeyediasareasymptomaticuntilafterthedamagetotheeyehasalreadyoccurred

sasaremindertoplanforregulareyeexaminationsto

maintainsightthroughoutalifetime.

_______________________________lmologist,MD

CATARACT

Whatisacataract?

*nappearslikeawindow

thatisfoggedwithsteam.

Whatcauscataractformation?

*Aging,themostcommoncau.

*Familyhistory.

*Steroidu.

*Injurytotheeye.

*Diabetes.

*Previouyesurgery.

*Long-termexposuretosunlight.

HowdoIknowifIhaveacataract?

*Thebestwayforearlydetectionisregulareyeexaminationsbyyourmedicaleyedoctor.

Therearemanycausofvisuallossinadditiontothecataractsuchasproblemsinvolving

eotherproblemxist,cataractremovalmaynotresultin

edoctorcantellyouhowmuchimprovementin

visionislikely.

Doesittakealongtimeforacataracttoform?

*Cataractdevelopmentvariesgreatlybetweenpatientsandisaffectedbythecauofthe

lly,ople,especially

diabeticsandyoungerpatients,mayfindthatcataractformationprogressrapidlyoverafew

monthsmakingitimpossibletoknowexactlyhowlongitwilltakeforthecataracttodevelop.

Whatisthetreatmentforcataracts?

*ymptomsarenotrestrictingyour

activity,cations,

exerci,opticaldevicesordietarysupplementshavebeenshowntostoptheprogressionor

preventcataracts.

surethatthesunglass

youwearscreenoutultraviolet(UV)lightraysoryourregulareyeglassarecoatedwitha

clear,anti-UVcoatingwillhelppreventorslowtheprogressionofcataracts.

HowdoIknowifIneedsurgery?

*Surgerportant

readandwatchTVin

comfort?Areyouabletocook,doyourshoppingandyardworkortakeyourmedications

withoutdifficulty?Dependingonhowyoufeelyourvisionisaffectingyourdailylife,youand

youreyedoctorwilldecidetogetherwhenitistheappropriatetimetodosurgery.

Whatisinvolvedwithcataractsurgery?

*Thissure

assistanceofamicroscope,thecloudylensisremovedandreplacedwithapermanent

intraocularlensimplant.

Rightafterthesurgeryyoushouldbeabletoimmediatelyperformallyournormalactivities

lneedtotakeeyedropsasdirectedbyyoureye

-upvisitsarenecessarytomakesurethesurgicalsiteishealingwithout

problems.

Thisprocedureisperformedonover1.4millionpeopleeachyearintheUnitedStatesalone,

95%ishighlysuccessfulprocedure,90%ofthetimevision

improvesunlessaproblemalsoexistswiththecornea,any

surgery,agoodresultcannotbeguaranteed.

_______________________________lmologist,MD