Cataract Surgery Quality Assurance



|[pic] | |

|David T. Brockbank, M.d. 6065 S. Fashion Blvd Ste 125, Murray, UT84107 (801)261-0726 (801)262-2838 (fax) | |

|Cataract Surgery Quality Assurance | |

|1 Day Post-op Report | |

| |

|Kindly mail, email or fax your exam findings. We appreciate your help. |

|Patient’s Name |DOB |Date of Surgery |

|Operative Eye |Date of Exam | |

| | | | |

|SUBJECTIVE |

| |

|OBJECTIVE | | | |

|Uncorrected VA distance |Conjunctiva | |

|OD 20 / | | |

|OS 20 / | | |

| |Wound | |

|Uncorrected VA near | | |

|OD 20 / | | |

|OS 20 / |Cornea | |

| | | |

|Refraction | | |

|Right __________ - ____________ x ________ 20/ | | |

| |AC | |

|Left ___________ - ____________ x ________ 20/ | | |

| | | |

| | | |

| |Pupil | |

| | | |

|IOP OD mm Hg OS mm |IOL | |

|Hg | | |

| | | |

| |Capsule | |

| |

|ASSESSMENT |PLAN |

| | | |

| | |

|Comments | |

| |

|Please contact Dr. Brockbank by telephone if you need assistance with any post-operative condition. |

|Physician Name |Signature | |

| | | |

|Please fax or mail a copy to Olympus Eye Associates. | |07/11 |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download