Cataract Surgery Documentation Suite

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Patient Face Sheet – Demographics

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Patient Identification

Last Name: First Name: Middle Initial: Preferred Name: Full Name (auto): Date of Birth: Age: Sex (legal): Gender Identity: Preferred Pronouns:

Contact Information

Street Address: Unit / Apt: City: State: ZIP: Primary Phone: Secondary Phone: Email:

Administrative

Medical Record Number (MRN): Primary Language: Race: Ethnicity: Marital Status: Occupation: Employer:

Insurance Information

Primary Insurance: Primary Policy #: Primary Group #: Secondary Insurance: Secondary Policy #: Subscriber Name: Subscriber DOB: Relationship to Subscriber:

Primary Care / Referring

Primary Care Physician: PCP Phone: Referring Physician: Referring Phone:

Emergency Contact

Contact Name: Relationship: Phone:

History & Physical – Cataract Surgery

Demographics auto‑fill from the Face Sheet. Yellow fields are required.

Patient Information

Patient Name:

DOB: MRN: Date:

Chief Complaint

Chief Complaint: If "Other", specify:

HPI

Course Eye(s) involved Duration Free-text HPI narrative

Medications & Allergies

Current medications (or "None") Allergy status Allergy details

Vitals

BP (mmHg): HR (bpm): RR (/min): Temp (°F): SpO₂ (%):

Assessment & Plan

Primary ocular diagnosis Planned procedure Plan details

Provider Signature

Name / Title Date

Eye Care Surgery Center

Operative Report

Facility:

Patient Name: DOB: MRN:

Surgeon:

Procedure:

Laterality:

Date of Surgery:

Add‑ons:
Kahook Dual Blade
Limbal Relaxation Incision (LRI)

Preoperative Diagnosis: Nuclear sclerotic cataract, OD (ICD-10: H25.11)

Postoperative Diagnosis: Nuclear sclerotic cataract, OD (ICD-10: H25.11), status post extraction

Indications: Visually significant lens opacity causing decreased BCVA with functional impairment in activities of daily living. Medical necessity confirmed by comprehensive history, exam and biometry with an expectation of improved status with the procedure.

Procedure Performed: Procedure: Cataract extraction with phacoemulsification and PCIOL (CPT: 66984).

Description of Procedure:

After informed consent was obtained detailing the risks, alternatives, benefits, and potential complications, The surgical right eye was identified, marked in the pre op area. A physical exam was performed insuring the suitability for the procedure. The patient was brought to the operating suite, placed in the supine position, and standard monitoring was applied. The eye was prepped with 5% Betadine solution drops and 10% to the skin, and draped in the usual sterile fashion. A time-out was performed: confirming patient ID (two identifiers), correct site, allergies (none), IOL type/lens power was verified. A lid speculum was placed. The patient received 4% Lidocaine MPF drops for anesthesia.

At the limbus, 3 mm was marked with calipers. The globe was fixated with 0.12 forceps, and a groove was placed with the superblade for one-third thickness at the temporal posterior limbus. A paracentesis was created to enter the anterior chamber to the left of the primary incision. Viscoelastic was instilled through the paracentesis. A 2.4mm clear corneal incision was created. With the cystitome a continuous curvilinear capsulorrhexis was created. Hydrodissection was performed, the nucleus rotated, and the nucleus was grooved, split and emulsified and the cortex was removed with irrigation/aspiration. The posterior capsule remained intact, the vitreous was not disturbed. The capsule was polished.

A diopter posterior chamber intraocular lens was implanted in the capsular bag and centered. Residual viscoelastic was removed, the wounds were hydrated, and were watertight with acceptable intraocular pressure. There were no complications. The speculum and drape were removed and an ocular hypotensive agent and antibiotic was instilled. The patient tolerated the procedure well and was transferred to recovery in stable condition, instructed to start prescribed drops and wear the shield at night. Follow‑up scheduled for the next day. Lens models:

Anesthesia: Topical 4% lidocaine drops; Monitored anesthesia care

Complications: None

Estimated Blood Loss: None

Counts: Sponge/sharp/needle counts - not applicable

Date:

Surgeon Signature:

David Malitz, MD

Complete all fields first

Perioperative & Postoperative Orders

Patient

Patient Name MRN Date

Preoperative Orders

Intraoperative Orders

Postoperative Medications

Topical Systemic

Activity & Protective Measures

Follow-Up

Medication Reconciliation

Patient

Patient Name MRN Date

Home Medications Before Admission

Perioperative Changes

Discharge Medication List

Consent for Cataract Surgery

Patient & Procedure

Patient Name MRN Eye Proposed procedure

Discussion Summary

Risks

Alternatives

Ohio Valley Eye Institute

Premium Intraocular Lens (IOL) / Refractive Services

Cataract surgery has evolved dramatically over the past several years. Once the cloudy lens is removed for restoration of vision, it must be replaced. The most common way is to place a monofocal intraocular lens implant that provides clear vision at one distance. With this option, glasses are often needed for near or intermediate vision.

The lenses we now use have undergone steady improvements, with the most dramatic improvements over the past several years. At Ohio Valley Eye Institute, we offer the most advanced technology IOLs, such as multifocal or presbyopia–correcting lenses, toric lenses, and accommodative IOLs. These lenses are designed to reduce or eliminate the need for glasses at various distances. Not all patients can use every lens; your surgeon will make a recommendation based on your eyes and lifestyle.

There are basically three zones of vision: distance, intermediate, and near. Any of these technologies can be used to improve one or more of these zones. By following the table below, you can select the technology that would be best suited to your particular needs.

Lens Options

Lens Type	Distance			Intermediate			Near			Astigmatism			Cost per Eye
Lens Type	Uncorrected	With Glasses	Notes	Uncorrected	With Glasses	Notes	Uncorrected	With Glasses	Notes	Corrected	Uncorrected	Notes	Facility Fee	Surgeon Fee	Total
Monofocal IOL	X		Best for distance only		X	Needs glasses		X	Needs readers		X	Astigmatism corrected with glasses	Covered	Covered	Covered
Monofocal Toric IOL	X		Astigmatism corrected		X	Needs glasses		X	Needs readers	X		Reduces astigmatism	$1,000.00	$900.00	$1,900.00
Multifocal IOL	X		Distance and near	X		Improved intermediate	X		Good near		May still need	For residual astigmatism	$1,800.00	$1,200.00	$3,000.00
Multifocal Toric IOL	X		Distance with astigmatism correction	X		Improved intermediate	X		Good near	X		Astigmatism reduced	$2,000.00	$1,300.00	$3,300.00
Crystalens (Accommodating IOL)	X		Good distance	X		Improved intermediate	X		Functional near		May still need	For residual astigmatism	$1,800.00	$1,200.00	$3,000.00

Patient Acknowledgment

I understand the differences between standard and premium intraocular lenses and the associated out‑of‑pocket costs.

Patient Name:

Signature:

Date: