Communications #13 - Progres Note for Right Eye one month and Left Eye one week post-op report to Optometrist (April 3, 2020, 10:30AM -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: 20200403103000 (2.16.840.1.113883.3.2820.10.1.3.10) , Date/Time: April 3, 2020 10:30AM -0400 - 11:30AM -0400
Documentation Of Care provision, Postoperative physical examination (procedure), Date/Time: April 3, 2020 10:30AM -0400 - 11:30AM -0400, Performer: Stan STEDYHAN
Author Dr Stan STEDYHAN, Authored On: April 3, 2020, 11:30AM -0400
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ASSESSMENT AND PLAN

  1. One week post-op report cataract extraction and IOL completed left eye on 03/26/2020
  2. One month post-op report cataract extraction and IOL completed right eye on 03/05/2020
  3. The patient is doing very well with their vision in both eyes at distance and has not experienced any problems. She is able to read briefly without any correction but finds that using reading glasses is better for extended reading
  4. The patient is using post-op meds according to instructions without complication

INSTRUCTIONS

  1. Advised to continue post-op medications as directed
  2. Call the office immediately if any change in vision or discomfort occurs
  3. Use reading glasses as neede
  4. Schedule One-moth post-op visit for left eye

VITAL SIGNS

No Information

SOCIAL HISTORY

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
Active
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 Active
moxifloxacin 5 MG/ML 403818 (RxNorm) qid for 2 weeks - left eye 2020-03-26 2020-04-09 Active
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
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 uncorrected distance
  1. Distance VA

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

  2. Near VA

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

IOP IOP

IOP OD 16mmHg
IOP OS 18mmHg

Slip-Lamp Slip-lamp exam
  1. surgical wound intact both eyes
  2. Conjunctiva

    no injection right eye
    mild injection left eye

  3. No corneal edema either eye
  4. Anterior chamber

    deep in both eyes
    right eye: no cells
    left eye: trace cells

  5. Posterior Chamber implant centered both eyes
Dilated fundus Dilated fundus exam normal each eye

posterior pole same as pre-surgical findings both eyes
Peripheral retina is flat 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 392d4b06-0061-46f7-9dd7-5d9a4eab0d87
Created On April 3, 2020, 10:30AM -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 physical examination (procedure)April 3, 2020 10:30AM -0400 - 11:30AM -0400
Performer - Stan STEDYHAN Contact Details Workplace: 33 Front St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-9898
Encounter
ID 20200403103000 (2.16.840.1.113883.3.2820.10.1.3.10)
Encounter Date April 3, 2020 10:30AM -0400 - 11:30AM -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