Chapter 6: Special Sensory Organs: Eye and Ear | Phuong Tao's Chart Note

CHART NOTE

Patient Name: Tao, Phuong
ID Number: TP9231
Examination Date: January 7, 20xx

SUBJECTIVE
This 58-year-old female patient presents with declining vision. She states that she failed her driver's license eye exam two weeks ago. She wants a "solution" because she drives herself and her mother to the grocery store and to doctor appointments on a monthly basis.

OBJECTIVE
Vision is 20/50 in the right eye and 20/70 in the left eye.

ASSESSMENT
Senile cataracts.

PLAN
Slight improvement in left eye can be obtained by increasing the prescription. Copy of prescription for left eye lens change was given to the patient. Driver's license form completed. Patient instructed to drive only during the daytime. I informed the patient that cataract surgery is warranted in the near future. I discussed the need for the procedure and its risks and benefits. She was given a pamphlet explaining the procedure and will follow up.