One week post-op right eye
Referral for evaluation for cataract extraction left eye
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: March 13, 2020 09AM -0500 - 10AM -0500 |
Documentation Of | Care provision, Postoperative follow-up visit - one week (procedure) , Date/Time: March 13, 2020 09AM -0500 - 10AM -0500, Performer: Yul SEEMORE |
Author | Dr Yul SEEMORE, Authored On: March 13, 2020, 10AM -0500 |
One week post-op right eye
Referral for evaluation for cataract extraction left eye
Date of Planned Services | Type of Intervention | Rationale | Provider | Location |
---|---|---|---|---|
(03/13/2020 - 04/09/2020 | Recommendation to continue with drug treatment (306806004) | Continue medications for right eye as previously directed |
Seemore, Yul
|
25 Fall St.
Atlanta, GA 30308 843-555-9876 |
(03/13/2020 - | Referral to ophthalmologist (308479007) | Visual complaints of blur in left eye |
Stedyhan, Stan
|
33 Front St.
Atlanta, GA 30308 843-555-9898 |
Time | Substance | Reaction | Severity | Status |
---|---|---|---|---|
01/20/1998 | egg | Hives | Moderate | Active |
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 | Active |
moxifloxacin 5 MG/ML | 403818 (RxNorm) | qid for 2 weeks - right eye | 2020-03-05 | 2020-03-19 | Active |
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 |
Active |
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 |
System | Finding |
---|---|
Visual Acuities | VA uncorrected OD 20/20 |
IOP | IOP OD 18mmHg |
Slip-Lamp | Slip-lamp exam
surgical wound intact |
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 |