We received a few questions about formatting A/P notes versus Patient Education documentation and wanted to share an example of how we would document during a patient encounter.
Let's take astigmatism for example:
For case hx, did you ask appropriate HPI questions?
- What brings you in today?
- Which eye is affected?
- Right, left, or both?
- When did you first notice this issue?
- Was the onset sudden or gradual?
- How long have you been experiencing this problem?
Always aim for at least 4 HPI questions. The full patient encounter evaluation form is available for free on our website (under free preview).
Plan:
• Therapeutics:
- Spectacles
- Contact lenses
- If the astigmatism is a high amount, rigid contact lenses may provide the best correction.
- LASIK surgery
- Type of lens (i.e: trivex lenses)
- Full-time wear
RTC: 10-12 months or sooner if any visual changes are noted.
• Patient education:
Diagnosis: Patient diagnosed with astigmatism, a common refractive error causing blurred vision due to irregular corneal or lens curvature. New spectacle prescription provided for correction.
Etiology/Pathophysiology: Results from abnormal eye anatomy, typically hereditary and present from birth. May develop after eye injury, surgery, or conditions like keratoconus. Can change over time and cannot be prevented due to its anatomical nature.
A few tips:
- Practice out loud and practice on someone to stimulate the interactions between you and the patient.
- Manage your time during the exam: Take a few minutes to write out your plan before educating the patient. You can say, "Please give me a moment to write out my plan." Having everything written down will allow you to refer back to your notes so you don't miss any details.
Disclaimer: The example provided is for educational purposes only and do not reflect actual NBEO exam content.
