SOAP / Chart / Progress Notes
Sample Name: Ophthalmology Progress Note - 2
Description: Ophthalmology followup visit note.
(Medical Transcription Sample Report)
At today's visit, the patient's visual acuities were measured at 20/40 in the right eye and 20/20 in the left eye without correction. Pupils were equal, round, and reactive to light with no afferent pupillary defects. Extraocular muscle movements were smooth and full. A slit-lamp examination was unremarkable revealing well-centered posterior chamber intraocular lenses. Intraocular pressures were measured at 16 mmHg in both eyes, by applanation. A dilated fundus examination was performed using a 78-diopter lens at the slit-lamp. The examination revealed non-proliferative diabetic retinopathy in both eyes with dot hemorrhages and posterior vitreous detachment in the right eye. There were no holes, tears, or detachments apparent around 360 degrees of either retina.
A fluorescein angiogram was ordered at today's visit to rule out macular edema. We have asked her to return in one to two weeks' time to discuss the results of her angiogram and possible intervention and will be sure to keep you apprised of her ongoing progress. A copy of the angiogram is enclosed for your records.
Keywords: soap / chart / progress notes, visual acuities, 78-diopter lens, extraocular muscle movement, afferent, angiogram, applanation, detachment, dilated fundus examination, fluorescein, hemorrhages, intraocular, intraocular lenses, left eye, posterior chamber, pupillary, retinopathy, right eye, slit-lamp, ophthalmology, lenses,