Eye Exam Under Anesthesia Documentation
Document all relevant details for eye examinations performed under anesthesia.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Procedure Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Indication for Anesthesia
*
Type of Anesthesia Used
*
General Anesthesia
Sedation
Other
Pre-Procedure Assessment (brief summary)
*
Intraoperative Eye Findings
*
Procedures Performed
*
Dilated Fundus Exam
Retinoscopy
Ocular Pressure Measurement
Photography
Other
Immediate Post-Procedure Status
*
Anesthesia Provider Name
*
First Name
Last Name
Ophthalmologist Name
*
First Name
Last Name
Provider Signature
*
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