Communications #14 - Progres Note for one month post-op report Left Eye to Ophthalmologist (April 27, 2020, 09:00AM -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)
Encounter ID: 20200305103000 (2.16.840.1.113883.3.2820.10.1.3.10) , Date/Time: April 27, 2020 09AM -0400 - 10AM -0400
Documentation Of Care provision, Postoperative follow-up visit - one month (procedure) , Date/Time: April 27, 2020 09AM -0400 - 10AM -0400, Performer: Yul SEEMORE
Author Dr Yul SEEMORE, Authored On: March 13, 2020, 10AM -0500
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ASSESSMENTS

One month post-op left eye

The patient is doing well with vision in both eyes following cataract extractions and the blur and glare she was experiencing, prior to surgery, is now gone

PLAN OF CARE

Date of Planned Services Type of Intervention Rationale Provider Location
(03/26/2020 - 05/13/2020) Recommendation to continue with drug treatment (306806004) Continue medications for left eye as previously directed Seemore, Yul
25 Fall St.
Atlanta, GA 30308
843-555-9876
(04/27/2020 - ) Single vision reading glasses (423013001) Use OTC reading glasses for extended reading when required Seemore, Yul
25 Fall St.
Atlanta, GA 30308
843-555-9876
(04/27/2020 - ) Complication of laser surgery (402759009) Call the office to report any change in vision or problems Seemore, Yul
25 Fall St.
Atlanta, GA 30308
843-555-9876
(07/15/2020 - 07/31/2020) Follow-up visit (procedure) (185389009) Schedule 3-month post-op visit Seemore, Yul
25 Fall St.
Atlanta, GA 30308
843-555-9876

SOCIAL HISTORY

No Information

VITAL SIGNS

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
Inactive
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 Inactive
moxifloxacin 5 MG/ML 403818 (RxNorm) qid for 2 weeks - left eye 2020-03-26 2020-04-09 Inactive
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 OS
20/20
IOP IOP OD 19mmHg
Slip-Lamp Slip-lamp exam

surgical wound intact
no injection of conjunctiva
no edma of cornea
no cells in anterior chamber
Posterior chamber IOL well centered
Peripheral retinal exam - flat with no tears

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 7bcbf640-0a1d-4b31-8c2d-cb99d5b4dfb3
Created On April 27, 2020, 09:00AM -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(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 follow-up visit - one month (procedure) April 27, 2020 09AM -0400 - 10AM -0400
Performer - Yul SEEMORE Contact Details Workplace: 25 Fall St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-9876
Encounter
ID 20200305103000 (2.16.840.1.113883.3.2820.10.1.3.10)
Encounter Date April 27, 2020 09AM -0400 - 10AM -0400
Encounter Location Dr. Yul Seemore (Workplace: United States
Atlanta, GA 30308
25 Fall St.)
Responsible Party Legal: SEEMORE Yul Contact Details Workplace: United States
Atlanta, GA 30308
325 Fall St.
 
Author Dr Yul SEEMORE Contact Details 25 Fall St.
Atlanta, Georgia 30308
US
Tel Workplace: +1-843-555-9876
Information Recipient Stan STEDYHAN Contact Details Workplace: 33 Front St.
Atlanta, GA 30308
USA
Tel Workplace: +1-843-555-9876