Operative Medical Report



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Optometric Referral Center POST-OPERATIVE REPORT PATIENT: DATE OF VISIT: SURGEON: CONSULTING O.D.: DATE OF SURGERY a CE/IOL OD a CE/IOL OS a YAG OD a YAG OS POST OPERATIVE DAY a OD 1 2 3 4 5 6 a OS 1 2 3 4 5 6 POST OPERATIVE WEEK a OD 1 2 3 4 5 6 7 8 9 10 11 12 a OS 1 2 3 4 5 6 7 8 9 10 11 12 PATIENT COMPLAINTS a OD a OS CURRENT MEDICATIONS: OD CORNEA: OS 1) Clear 2) Striae 3) Edema Neg Neg Neg Pos Pos Pos 1) Clear 2) Striae 3) Edema Neg Neg Neg Pos Pos Pos 1) Quiet 2) Cells/Flare 3) Hypopyon Neg Neg Neg Pos +1 +2 +3 +4 Pos 1) Quiet 2) Cells/Flare 3) Hypopyon Neg Neg Neg Pos +1 +2 +3 +4 Pos Round Irregular Round Irregular Neg Neg Neg Pos Pos Pos Neg Neg Neg Pos Pos Pos POSTERIOR CAPSULE: Clear Hazy Clear Hazy IMPLANT: Centered Off Center Centered Off Center Neg Neg Neg Pos Pos Pos Neg Neg Neg Pos Pos Pos ANTERIOR CHAMBER: PUPIL: INCISION: 1) Sutures Intact 2) Gaping Wound 3) Prolapse of Iris FUNDUS: IOP: 1) Normal 2) Hemorrhage 3) Macular Edema OD OS 1) Sutures Intact 2) Gaping Wound 3) Prolapse of Iris 1) Normal 2) Hemorrhage 3) Macular Edema UNCORRECTED VA: OD 20/ OS 20/ REFRACTION: OD 20/ OS 20/ Rx GIVEN: OD x Add + OS x Add + PLAN: Follow up: Medication: a Routine a Refraction a days a weeks a months With: a O.D..

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