One month post-op left eye
The patient is doing well with vision in both eyes following cataract extractions and the blur and glare she was experiencing, prior to surgery, is now gone
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: April 27, 2020 09AM -0400 - 10AM -0400 |
Documentation Of | Care provision, Postoperative follow-up visit - one month (procedure) , Date/Time: April 27, 2020 09AM -0400 - 10AM -0400, Performer: Yul SEEMORE |
Author | Dr Yul SEEMORE, Authored On: March 13, 2020, 10AM -0500 |
One month post-op left eye
The patient is doing well with vision in both eyes following cataract extractions and the blur and glare she was experiencing, prior to surgery, is now gone
Date of Planned Services | Type of Intervention | Rationale | Provider | Location |
---|---|---|---|---|
(03/26/2020 - 05/13/2020) | Recommendation to continue with drug treatment (306806004) | Continue medications for left eye as previously directed |
Seemore, Yul
|
25 Fall St.
Atlanta, GA 30308 843-555-9876 |
(04/27/2020 - ) | Single vision reading glasses (423013001) | Use OTC reading glasses for extended reading when required |
Seemore, Yul
|
25 Fall St.
Atlanta, GA 30308 843-555-9876 |
(04/27/2020 - ) | Complication of laser surgery (402759009) | Call the office to report any change in vision or problems |
Seemore, Yul
|
25 Fall St.
Atlanta, GA 30308 843-555-9876 |
(07/15/2020 - 07/31/2020) | Follow-up visit (procedure) (185389009) | Schedule 3-month post-op visit |
Seemore, Yul
|
25 Fall St.
Atlanta, GA 30308 843-555-9876 |
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 | 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 |
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 |
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 OS 20/20 |
IOP | IOP OD 19mmHg |
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 |