Focus Eye Irritation Exam
The EE clinic visit for (non-work related) **** eye irritation or pain/ eye injury. EE reports irritation with no visual changes/ no photophobia/eye pruritus/tearing, the associated symptoms lasting**** x 1 day. Pertinent Info: EE reports ***** use of Glasses/Contacts, denies history of recent(non-work related) injury (explain)/infection/chronic eye disorder. Current Medications: Denied **** Drug Allergies: NKDA**** Female: Denies chance of pregnancy ***** Visual Eye Inspection: ***** Eyelid swelling/redness/visible foreign body/open wounds/crusting/discharge purulent/discharge white/discharge watery. Pupils: **** equal, round, and reactive to light Treatment ******OTC Purified Water flush|NDC: 0000-0000-00 Lot: Exp:0/202 Dose: Manufacturer OTC Recommendation/OTC Lubricating eye drops NDC: 0000-0000-00 Lot: Exp:0/202 Dose: Manufacturer OTC Recommendation /Allergy eye drops NDC: 0000-0000-00 Lot: Exp:0/202 Dose: Manufacturer OTC Recommendation OTC medication (non-work related) self-selected by the employee. Selected OTC Medication information: NDC: 0000-0000-00 Lot: Exp:0/202 Dose: Manufacturer OTC Recommendation Medication directions, warnings, and directions were available to the employee at the time of the request. If there is a change in the acute discomfort, the recommendation is to immediately contact your PCP or seek emergency medical services.
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 185 boilerplate words
More SOAPnotes by this Author:
Send Feedback for this SOAPnote