HTML Preview Procedure Note page number 1.
Laser Procedure Note
Patient Name ______________________________ Date______________________
1. Pre procedure diagnosis
_______________________________________________________________________________
2. Procedure and Eye
________________________________________________Eye:____________________________
3. Pre procedure topical medications administered (and time)
________________________________________________________________________________
4. Vital signs
BP _____/______ HR________ Acuity – OD:________ OS:_________
5. IOP: OD__________ OS___________ Method:____________ @_________AM/PM
6. Patient dilated
Yes / No ( Tropicamide / Phenylephrine )
7. Miotic used
Yes / No (____% Pilocarpine)
8. Summary of laser procedure
YAG
ARGON / GREEN
SLT
Energy (mJ):
Duration (sec):
Duration: 3nsec
Pulse Setting:
Spot Size (µm):
Spot Size: 400 µm
Applications (#):
Power (mW):
Energy (mJ):
Lens Used:
Applications (#):
Applications (#):
Lens Used:
Lens Used:
9. Complications
______________________________________________________________________________
10. Post-op medications instilled in office
______________________________________________________________________________
11. Post-op IOP: OD__________ OS___________ Method:____________ @_________AM/PM
12. Post-op medications prescribed and follow up
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________________________
________________________________________