Communications #15 - Progres Note for three month post-op report to Ophthalmologist (June 4, 2020, 09:00AM -0400)

Patient Legal: Clare M TESCA Date of Birth: February 14, 1952 (68yr) Gender: Female Patient-ID:  123456789 (SSN), 404.1 (1.3.6.1.4.1.115)
Encounter ID: 20200305103000 (2.16.840.1.113883.3.2820.10.1.3.10) , Date/Time: June 4, 2020 09AM -0400 - 10AM -0400
Documentation Of Care provision, Postoperative follow-up visit - three month (procedure) , Date/Time: June 4, 2020 09AM -0400 - 10AM -0400, Performer: Yul SEEMORE
Author Dr Yul SEEMORE, Authored On: June 4, 2020, 10AM -0400
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ASSESSMENTS

3 month post-op report both eyes following cataract extractions

This is the final post-op communication. The patient will be released back to regular annual exams after this visit

The patient has not experienced any change in her vision or any problems other than difficulty viewing her computer monitor when doing virtual conferences for work. She needs to be able to see other items in her room and the monitor but is unable to do so when wearing her reading glasses

PLAN OF CARE

Date of Planned Services Type of Intervention Rationale Provider Location
(06/01/2021 - 06/30/2021) Comprehensive eye examination (78831002) Recommended yearly routine eye exams to patient Seemore, Yul
25 Fall St.
Atlanta, GA 30308
843-555-9876

INSTRUCTIONS

  1. Recommended a pair of glasses that have Office Lenses to allow her to see distance and read but also includes a large central area to view the computer monitor
  2. The patient was educated on the possibility of developing a “secondary cataract” which is a film that develops on the posterior capsule which can easily be removed with a simple in-office laser procedure. If it should occur, the laser treatment permanently eliminates the film from developing again in the future
  3. The patient was instructed to call the office if they experience any change in their vision
  4. The patient was released from post-op care
  5. Instructed to schedule a yearly routine eye exam

SOCIAL HISTORY

No Information

VITAL SIGNS

No Information

ALLERGIES AND ADVERSE REACTIONS

Time Substance Reaction Severity Status
01/20/1998 egg Hives Moderate Active

MEDICATIONS

Surgical Medications (Right Eye)
Name Code Instructions Start Date Stop Date Status
ketorolac tromethamine 5 MG/ML 860107 (RxNorm) qid for 2 weeks - right eye 2020-03-05 2020-03-19 Inactive
moxifloxacin 5 MG/ML 403818 (RxNorm) qid for 2 weeks - right eye 2020-03-05 2020-03-19 Inactive
prednisolone acetate 10 MG/ML 1376335 (RxNorm) qid for 2 weeks then taper - right eye
tid for 1 week - right eye
bid for 1 week - right eye
qd for 1 week - right eye
2020-03-05
2020-03-20
2020-03-28
2020-04-05
2020-03-19
2020-03-27
2020-04-04
2020-04-12
Inactive
Surgical Medications (Left Eye)
Name Code Instructions Start Date Stop Date Status
ketorolac tromethamine 5 MG/ML 860107 (RxNorm) qid for 2 weeks - left eye 2020-03-26 2020-04-09 Inactive
moxifloxacin 5 MG/ML 403818 (RxNorm) qid for 2 weeks - left eye 2020-03-26 2020-04-09 Inactive
prednisolone acetate 10 MG/ML 1376335 (RxNorm) qid for 2 weeks then taper - left eye
tid for 1 week - left eye
bid for 1 week - left eye
qd for 1 week - left eye
2020-03-26
2020-04-10
2020-04-18
2020-04-26
2020-04-09
2020-04-17
2020-04-25
2020-05-03
Inactive
Active Medications
Name Code Instructions Start Date Stop Date Status
Crestor 5 mg 859426 (RxNorm) 1 tablet by mouth once a day for 90 2019-07-28 Active
metformin 1,000 mg 861004 (RxNorm) 1 tablet by mouth twice a day for 180 2014-04-20 Active
Invokana 100mg 50458-140-01 (NDC) 1 tablet by mouth once a day for 90 2019-07-28 Active
lisinopril 10 mg 314076 (RxNorm) 1 tablet by mouth once a day for 90 2019-07-28 Active

PHYSICAL EXMAMINATION

Clinical Findings
System Finding
Visual Acuities VA without correction
  1. Distance:

    right eye: 20/20
    left eye: 20/20

  2. Near:

    right eye: 20/25
    left eye: 20/25-

Anterior Chamber Cornea clear both eyes
Conjunctiva clear both eye without injection
Anterior chamber deep and quiet both eyes
Posterior Chamber Posterior pole unchanged
Peripheral retina flat without tears or elevation both eyes

PATIENT CARE TEAMS

  • Long Term Care Team ( Active) (01/01/2005 - )
    Member Role on Team Status Date
    Dr. Joseph Gooddoc, MD (NPI: 2734441159 ) Primary Care Physician (Active) 2005 - current
    Maka Felgood Diabetic Educator (Active) 2014 - current
    Dr. Arthur Feetler, DPM (NPI: 8402871106) Podiatrist (Active) 2018 - current
    Dr. Donald Singletooth, DDS (NPI: 8477778822) Dentist (Active) 1990 - current
    Dr. Yul Seemore, OD (NPI: 1973535929) Optometrist (Active) 2020 - current
    Dr. Stan Stedyhan, MD (NPI: 2173512387) Ophthalmologist (Active) 2020 - current

PAYERS

No Information
Document
ID 11aa9f5f-fa8d-4022-9c1b-310e68bc03d4
Created On June 4, 2020, 09:00AM -0400
Custodian Wood River Health Services, LLC Contact Details Workplace: 800 Spring St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-2234
 
Patient Legal: Clare M TESCA Contact Details Home Primary: 3704 Irish Lane
Atlanta, GA 30301
US
Tel Home Primary: +1(608)-758-0515
Date of Birth February 14, 1952 (68yr) Gender Female
Race Black or African American Ethnicity Not Hispanic or Latino
Patient-IDs 123456789 (SSN)
404.1 (1.3.6.1.4.1.115)
Language Communication
en, Expressed spoken, Excellent, preferred: yes
Provider Organization
Wood River Health Services, LLC
ID 9999999999 (NPI), jgrue@directaddress.net (1.3.6.1.4.1.41179.2.1), 2.16.840.1.113883.1.111.12345
Contact Details (Organization) 800 Spring St.
Atlanta, GA 30308
US
Tel Workplace: +1-843-555-2234, Mail Workplace: jgrue@directaddress.net
 
Documentation Of - care provision Postoperative follow-up visit - three month (procedure) June 4, 2020 09AM -0400 - 10AM -0400
Performer - Yul SEEMORE Contact Details Workplace: 25 Fall St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-9876
Encounter
ID 20200305103000 (2.16.840.1.113883.3.2820.10.1.3.10)
Encounter Date June 4, 2020 09AM -0400 - 10AM -0400
Encounter Location Dr. Yul Seemore (Workplace: United States
Atlanta, GA 30308
25 Fall St.)
Responsible Party Legal: SEEMORE Yul Contact Details Workplace: United States
Atlanta, GA 30308
325 Fall St.
 
Author Dr Yul SEEMORE Contact Details 25 Fall St.
Atlanta, Georgia 30308
US
Tel Workplace: +1-843-555-9876
Information Recipient Stan STEDYHAN Contact Details Workplace: 33 Front St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-9876