Enhance Visual HealthDocumentation withPrecision
From subtle acuity changes to post-op care, our template provides a structured format to document patient encounters with confidence, clarity, and speed.
Specialized for Eye Care: Built for routine exams, acute evaluations, and surgical follow-ups in any ophthalmology setting.
🔍 Why an Ophthalmology Template Matters
The eye is a complex, highly specialized organ. A clear, standardized format ensures that no detail is missed and communication with other providers is seamless.
Consistent & Complete Exams
Ensures no critical findings are missed during routine or complex eye examinations.
Efficient Data Recording
Quickly document ocular history, test results, and imaging interpretations.
Structured Surgical Workflow
Streamlines documentation for pre-operative, intra-operative, and post-op care.
Accurate Billing & Coding
Aligns clinical notes with ICD-10 and CPT standards for proper reimbursement.
Enhanced Communication
Provides clear, standardized notes for co-management and referrals.
👩⚕️ Who Uses This Template?
Ophthalmologists
Optometrists
Ophthalmic Technicians & Assistants
Retina, Glaucoma, and Cornea Specialists
Pediatric & Neuro-Ophthalmologists
Surgical Eye Centers & Hospitals
🧩 Inside the Ophthalmology Template
Our template guides you through every essential aspect of the eye exam, diagnostics, and care planning—without slowing you down.
1. Chief Complaint (CC)
The patient's primary vision concern or ocular symptom in their own words.
Example:
"Blurry vision in left eye for 3 days."
2. History of Present Illness (HPI)
Document the onset, duration, severity, and progression of symptoms.
Key Components:
- Laterality (unilateral vs. bilateral)
- Type of visual change (blurred, distorted, field loss)
- Associated symptoms (pain, floaters, photophobia)
- History of trauma or recent interventions
Example:
"Patient reports gradual blurring in left eye, worse in the morning, no associated pain or redness."
3. Ocular & Medical History
Document past ocular conditions and relevant systemic diseases.
Key Components:
- Glaucoma, cataracts, AMD, diabetic retinopathy
- Diabetes, hypertension, autoimmune diseases
- Family history of significant eye conditions
Example:
"History of Type 2 Diabetes for 10 years, no known family history of glaucoma."
4. Medications & Allergies
Include all ophthalmic drops, systemic meds, supplements, and drug allergies.
Example:
"Latanoprost 1 gtt OU HS. Metformin 500mg BID. NKDA."
5. Review of Systems (ROS)
A focused ROS related to visual and neurological complaints.
Example:
"+ Blurred vision, - eye pain, - photophobia, - diplopia, - headaches."
6. Visual Function & Exam Findings
A comprehensive section to document all objective exam data systematically.
Key Components:
- Visual Acuity (VA): OD: 20/20, OS: 20/40
- Pupils: Equal, round, reactive to light; no RAPD
- Extraocular Movements (EOM): Full and smooth
- Intraocular Pressure (IOP): OD: 16 | OS: 18
- Slit Lamp Exam: Cornea, conjunctiva, lens status
- Dilated Fundus Exam (DFE): Disc, vessels, macula, periphery
Example:
"VA OD: 20/20, OS: 20/40. IOP OD: 16, OS: 18. DFE shows drusen OS."
7. Diagnostic Tests & Imaging
Include interpretations of OCT, Fundus Photos, Visual Fields, etc.
Example:
"OCT OS: Subretinal fluid present; suggestive of central serous retinopathy."
8. Assessment/Diagnosis
Provide ocular diagnoses with laterality and specific ICD-10 codes.
Example:
"H35.31 – Nonexudative age-related macular degeneration, left eye."
9. Plan of Care
Outline medical management, surgical planning, education, and follow-up.
Key Components:
- Medication initiation/adjustment (e.g., drops, injections)
- Surgical recommendations (e.g., cataract extraction)
- Referrals (e.g., to retina or glaucoma specialist)
- Lifestyle/safety guidance and next visit timeline
Example:
"Start AREDS2 vitamins, monitor with OCT in 6 weeks, advise use of Amsler grid daily."
🧪 Use Case Examples
Glaucoma Monitoring
Diabetic Eye Exam
Cataract Evaluation
⚠️Common Ophthalmology Note Pitfalls
- !Missing laterality (OD, OS, OU)—critical for diagnosis and billing
- !Unclear exam structure, especially for slit lamp and fundus exams
- !Not including an interpretation summary for imaging tests
- !A generic plan that isn't customized to diagnosis and severity
✅Best Practices for Ophthalmology Notes
- ✓Always include Visual Acuity (VA), IOP, and fundus findings
- ✓Document both subjective symptoms and objective measurements
- ✓Be specific in laterality and use standardized terminology
- ✓Align diagnosis and procedure codes with clinical notes
- ✓Capture patient education and informed consent when relevant
🛡️Compliance & Billing Alignment
Our Ophthalmology Template ensures:
- ✓ICD-10 accuracy for all eye conditions, including laterality
- ✓CPT compliance for office visits, procedures, and imaging
- ✓Audit-readiness for surgical cases and complex medical management
- ✓Comprehensive documentation for MIPS/QPP reporting
Simplify Eye Care Documentation with SCRIBE AI
Our template integrates AI-powered support to help you document faster, maintain accuracy for legal and billing protection, and support better patient outcomes with clearer records.
👁️ Conclusion
Whether managing diabetic eye disease, evaluating surgical candidates, or tracking glaucoma, great eye care starts with great documentation. Our template brings structure, precision, and speed to every exam so you can focus more on your patients. Start seeing documentation differently. Start with SCRIBE AI.