Communications #10 - Pre-surgical workup report from Ophthalmologist to Optometrist (March 19, 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: 20200305103000 (2.16.840.1.113883.3.2820.10.1.3.10) , Date/Time: March 5, 2020 10:30AM -0400 - 11:30AM -0400
Documentation Of Care provision, Preoperative care, Date/Time: March 19, 2020 10:30AM -0400 - 11:30AM -0400, Performer: Lucy PREOP
Author Dr Stan STEDYHAN, Authored On: March 19, 2020, 11:30AM -0400
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ASSESSMENT AND PLAN

  1. Patient scheduled for cataract surgery on left eye on 03/26/2021
  2. The patient has selected to have the surgical follow-up visits co-managed with your office, if possible

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 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
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
The patient was found to have nuclear cataracts left eye causing significant glare to warrant surgical extraction with IOL
The patient selected to have a multifocal IOL implanted in each eye

The patient selected laser assisted catalys surgery

All other clinical findings were consistent with referral note

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 d781da24-d628-4b46-bd0c-8cf287f773e6
Created On March 19, 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 Preoperative careMarch 19, 2020 10:30AM -0400 - 11:30AM -0400
Performer - Lucy PREOP Contact Details Workplace: 33 Front St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-9898
Encounter
ID 20200305103000 (2.16.840.1.113883.3.2820.10.1.3.10)
Encounter Date March 5, 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