Communications #8 - Progres Note for one week post-op report Right Eye to Ophthalmologist (March 13, 2020, 09:00AM -0500)

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 13, 2020 09AM -0500 - 10AM -0500
Documentation Of Care provision, Postoperative follow-up visit - one week (procedure) , Date/Time: March 13, 2020 09AM -0500 - 10AM -0500, Performer: Yul SEEMORE
Author Dr Yul SEEMORE, Authored On: March 13, 2020, 10AM -0500
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ASSESSMENTS

One week post-op right eye

Referral for evaluation for cataract extraction left eye

PLAN OF CARE

Date of Planned Services Type of Intervention Rationale Provider Location
(03/13/2020 - 04/09/2020 Recommendation to continue with drug treatment (306806004) Continue medications for right eye as previously directed Seemore, Yul
25 Fall St.
Atlanta, GA 30308
843-555-9876
(03/13/2020 - Referral to ophthalmologist (308479007) Visual complaints of blur in left eye Stedyhan, Stan
33 Front St.
Atlanta, GA 30308
843-555-9898

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 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
Visual Acuities VA uncorrected OD
20/20
IOP IOP OD 18mmHg
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 670a9b1c-5714-4634-8b9f-d2452f855c6e
Created On March 13, 2020, 09:00AM -0500
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 week (procedure) March 13, 2020 09AM -0500 - 10AM -0500
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 March 13, 2020 09AM -0500 - 10AM -0500
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