Communication #11 - Operative note from Ophthalmology to Optometry (March 26, 2020, 10:00AM -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)
Consent ID: 629deb70-5306-11df-9879-0800200c9a66 , Code: Procedure consent, Status: completed
Encounter ID: 20200326100000 (2.16.840.1.113883.3.2820.10.1.3.10) , Date/Time: from March 26, 2020, 08AM -0400
Documentation Of Care provision, Cataract extraction and insertion of intraocular lens (procedure), Date/Time: March 26, 2020 08:00AM -0400 - 10:00AM -0400, Primary Performer: Dr. Stan STEDYHAN
Author Dr Stan STEDYHAN, Authored On: March 26, 2020, 10:00AM -0400
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PROCEDURE ANESTHESIA

Following a detailed discussion by the anesthesiologist of the risks and benefits of the different anesthesiology delivery options, the patient agreed to I.V. sedation along with topical anesthesia (1% sterile preservative-free Lidocaine) with monitored anesthesia care (MAC).

COMPLICATIONS

No complications documented

SURGICAL PROCEDURE

The patient was prepped and draped in the usual sterile fashion. 0.3 ml of 1% sterile preservative-free lidocaine was injected into the anterior chamber. A keratome was used to make a superior clear corneal incision. Viscoelastic was injected into the anterior chamber. A continuous curvilinear capsulorrhexis was created. Paracentesis was performed at the 12:00 o’clock position. The nucleus was hydrodissected with balanced salt solution. Phacoemulsification of the nucleus was carried out, first sculpting the nucleus and then dividing and cracking it using the phaco tip and a nucleus chopper introduced through the paracentesis site. After removal of all nuclear material, cortical material was removed with the I & A handpiece. The posterior capsule was polished. Viscoelastic was again injected into the bag and the intraocular lens inserted. The viscoelastic was then removed using the I & A handpiece.
Balanced salt solution was injected to normalize intraocular pressure. The wound was hydrated and checked and found to be watertight.

PLAN OF TREATMENT

Planned Activity Planned Date
Anesthetic (398172005)

The risks and benefits of surgery were discussed at length with the patient stressing that the visual outcome could not be guaranteed. The patient was agreeable and elected to proceed.

20200326
Cataract extraction and insertion of intraocular lens (73761001) 20200326

PREOPERATIVE DIAGNOSIS

Diagnosis (SNOMED) ICD10 Code
Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral (1551000119108) E11.3293
Age-related nuclear cataract, bilatera (678601000119100) H25.13

POSTOPERATIVE DIAGNOSIS

Diagnosis (SNOMED) ICD10 Code
Pseudophakia of left eye (11673711000119103) Z96.1

PROCEDURE DESCRIPTION

  1. Phacomulsification Left eye
  2. Intraocular lens implantation Left eye
  3. New Lens Technology Left eye

Routine-66984

PROCEDURE IMPLANTS

LENS IMPLANT INFORMATION:
  • AMO
  • AAB00
  • +21.00
  • 7434642103
  • Expiration: 03/19/2030

PROCEDURE DISPOSITION

No Information

PROCEDURE ESTIMATED BLOOD LOSS

No Information

PROCEDURE FINDINGS

No Information

PROCEDURE SPECIMENS TAKEN

No Information
Document
ID TT999 (2.16.840.1.113883.19.5.99999.1)
Version 1
Set‑ID sTT999 (2.16.840.1.113883.19.5.99999.19)
Created On March 26, 2020, 10:00AM -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(843)-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
Consent Procedure consent
 
Documentation Of - care provision Cataract extraction and insertion of intraocular lens (procedure)March 26, 2020 08:00AM -0400 - 10:00AM -0400
Primary performer - Attending Physician - Ophthalmologist Dr. Stan STEDYHAN of Dr. Stan Stedyhan Contact Details 33 Front St.
Atlanta, GA 30308
US
Tel Home Primary: +1-843-555-9898
Encounter
ID 20200326100000 (2.16.840.1.113883.3.2820.10.1.3.10)
Encounter Date from March 26, 2020, 08AM -0400
Encounter Location Dr. Stan Stedyhan (Workplace: United States
Atlanta, GA 30308
33 Front St.)
Responsible Party Legal: STEDYHAN Stan Contact Details Workplace: United States
Atlanta, GA 30308
33 Front St.
attender Legal: PREOP Lucy Contact Details Workplace: United States
Atlanta, GA 30308
33 Front St.
 
Author Dr Stan STEDYHAN Contact Details 33 Front St.
Atlanta, Georgia 30308
US
Tel Workplace: +1-843-555-9898
Information Recipient Yul SEEMORE Contact Details Workplace: 25 Fall St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-9876