AI Scribe for Ophthalmologists
Document eye exams, surgical procedures, and imaging results in seconds. PatientNotes captures visual acuity, IOP, retinal findings, and generates comprehensive ophthalmology notes.
Documentation for Every Ophthalmology Visit
From routine exams to complex surgeries, PatientNotes handles all ophthalmology documentation needs
Comprehensive Eye Exams
Complete ophthalmologic examinations with visual acuity, refraction, IOP, slit lamp, and dilated fundus evaluation.
Cataract Surgery
Operative notes for phacoemulsification with IOL implantation including biometry, lens selection, and surgical details.
Retinal Evaluations
Detailed retinal exams with OCT, fluorescein angiography, macular assessment, and diabetic retinopathy grading.
Glaucoma Management
IOP monitoring, visual field interpretation, optic nerve assessment, and medication management for glaucoma.
Laser Procedures
YAG capsulotomy, SLT, PRP, and focal laser documentation with laser parameters and treatment response.
Corneal Evaluations
Corneal topography, dry eye assessment, contact lens fitting, and keratoconus evaluation.
Ophthalmology-Specific Features
Built for the unique documentation needs of eye care
Visual Acuity Documentation
Capture distance and near acuity with and without correction using Snellen, LogMAR, or other notation. Tracks pinhole improvement.
IOP Tracking
Document intraocular pressure measurements with time of day, method (applanation, iCare, etc.), and pachymetry correction.
Slit Lamp Findings
Structured anterior segment examination: lids/lashes, conjunctiva, cornea, AC, iris, lens. Uses standard grading scales.
Fundus Examination
Document optic disc (C/D ratio, color, contour), macula (foveal reflex, edema, drusen), vessels, and peripheral retina.
Imaging Integration
Incorporate OCT measurements, visual field results, fundus photos, and fluorescein findings into clinical documentation.
Surgical Templates
Pre-built templates for cataract surgery, vitrectomy, glaucoma surgery with procedure-specific fields and complications.
Sample AI-Generated Ophthalmology Note
See how PatientNotes documents a comprehensive eye exam
COMPREHENSIVE OPHTHALMOLOGIC EXAMINATION
Chief Complaint: 68-year-old patient presents for annual eye exam. Reports gradually worsening distance vision over past year, especially with night driving. Denies pain, redness, or flashes/floaters.
MEDICAL HISTORY:
- Type 2 diabetes mellitus (A1c 6.8% - well controlled)
- Hypertension
- Hyperlipidemia
Current medications: Metformin, Lisinopril, Atorvastatin
Allergies: NKDA
OCULAR HISTORY:
- Last eye exam 12 months ago
- Wears glasses for distance (outdated prescription from 3 years ago)
- No history of eye surgery or trauma
- Family history: Mother with glaucoma
VISUAL ACUITY:
Distance (uncorrected) Distance (corrected) Near (corrected)
OD (Right): 20/40 20/25 J2
OS (Left): 20/50 20/30 J2
REFRACTION:
OD: -1.25 -0.75 x 180 → 20/25
OS: -1.50 -1.00 x 175 → 20/30
EXTRAOCULAR MOTILITY:
Full in all positions of gaze OU. No restriction or diplopia.
PUPILS:
OD: 4mm in light, 6mm in dark, no RAPD
OS: 4mm in light, 6mm in dark, no RAPD
CONFRONTATION VISUAL FIELDS:
Full to finger counting OU
INTRAOCULAR PRESSURE (3:15 PM):
OD: 16 mmHg (Goldmann applanation)
OS: 17 mmHg (Goldmann applanation)
Central corneal thickness: OD 545 μm, OS 548 μm
SLIT LAMP EXAMINATION:
Lids/Lashes: Normal, no blepharitis
Conjunctiva: White and quiet OU
Cornea: Clear, no infiltrates or edema OU
Anterior Chamber: Deep and quiet OU
Iris: Normal architecture OU
Lens:
OD: 2+ nuclear sclerosis, trace cortical changes
OS: 2+ nuclear sclerosis, 1+ cortical opacities
DILATED FUNDUS EXAMINATION (1% Tropicamide, 2.5% Phenylephrine):
Optic Disc:
OD: Pink, sharp margins, C/D ratio 0.3, no pallor or edema
OS: Pink, sharp margins, C/D ratio 0.35, no pallor or edema
Macula:
OD: Flat, good foveal reflex, no edema or exudates
OS: Flat, good foveal reflex, no edema or exudates
Vessels:
OD: Normal caliber, no tortuosity, AV ratio 2:3, no hemorrhages
OS: Normal caliber, no tortuosity, AV ratio 2:3, no hemorrhages
Periphery:
OD: No holes, tears, or detachment. Vitreous attached.
OS: No holes, tears, or detachment. Vitreous attached.
DIABETIC RETINOPATHY SCREENING:
No evidence of diabetic retinopathy OU (severity level 10 per AAO grading)
ASSESSMENT:
1. Age-related cataracts, bilateral (moderate nuclear sclerosis) - symptomatic
2. Myopia with astigmatism
3. Type 2 diabetes without diabetic retinopathy
4. Intraocular pressures within normal limits
PLAN:
1. Discussed cataract surgery options given patient's visual complaints and impact on daily activities (night driving)
2. Patient interested in proceeding with cataract surgery
3. Schedule OD cataract surgery with IOL implantation
4. Preoperative biometry and IOL calculations to be performed
5. Target: Monofocal IOL for distance, will need readers post-operatively
6. Updated spectacle prescription provided for interim use
7. Continue annual diabetic eye exams
8. Patient counseled on importance of good glycemic control
9. Follow-up: Post-operative day 1 after cataract surgery
Dilated exam findings and surgical options discussed in detail. Patient's questions answered. Informed consent process initiated.Intelligent ICD-10 Suggestions
PatientNotes suggests the codes most commonly used in ophthalmology
H25.11Age-related nuclear cataract, right eyeH40.11X1Primary open-angle glaucoma, right eye, mild stageH35.31Nonexudative age-related macular degeneration, right eyeE11.319Type 2 diabetes mellitus with unspecified diabetic retinopathyH52.223Regular astigmatism, bilateralH04.123Dry eye syndrome, bilateralH43.811Vitreous degeneration, right eyeH26.063Combined forms of age-related cataract, bilateralAI suggests relevant codes based on your documentation—review and select with one click.
Frequently Asked Questions
Can PatientNotes document comprehensive eye exams?
Yes. PatientNotes captures detailed eye exams including visual acuity, refraction, IOP, slit lamp findings, dilated fundus exam, and ancillary testing. The AI organizes findings in standard ophthalmologic format.
Does PatientNotes handle surgical documentation for eye procedures?
Yes. PatientNotes creates comprehensive operative notes for cataract surgery, glaucoma procedures, retinal surgery, and laser treatments. Documentation includes preoperative diagnosis, procedure details, IOL calculations, and post-operative care.
How does PatientNotes document retinal findings?
PatientNotes documents detailed retinal examinations including optic disc assessment, cup-to-disc ratio, macula evaluation, vascular changes, and peripheral retinal findings. It integrates OCT and fundus photo findings.
Can PatientNotes track glaucoma patients and IOP trends?
Yes. PatientNotes tracks intraocular pressure measurements, visual field progression, OCT RNFL thickness, medication regimens, and target IOP goals. It monitors glaucoma progression over time.
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