Ophthalmology: Step-by-Step Guide on How to Write SOAP Notes

Updated January 2026

Ophthalmology SOAP notes require precise documentation of specialized examinations and measurements unique to eye care. From visual acuity testing to detailed fundus examinations, comprehensive documentation is essential for tracking disease progression, justifying treatment decisions, and providing medicolegal protection. This guide provides detailed instructions for documenting ophthalmology encounters across all subspecialties.

Create Your Ophthalmology SOAP Note in 2 Minutes

Start with 20 free SOAP notes. No credit card required.

Try Free on Web

Unique Aspects of Ophthalmology Documentation

Ophthalmology documentation differs from general medical notes in several key ways:

1. Bilateral Documentation: Almost all findings must be documented for both eyes separately (OD/OS/OU)
2. Quantitative Measurements: Visual acuity, IOP, refractive error require precise numerical documentation
3. Specialized Equipment: Document examination technique (slit lamp, fundoscopy, OCT, visual fields)
4. Anatomical Precision: Use standardized terminology (clock hours, zones, specific anatomical structures)
5. Progressive Conditions: Many eye diseases require comparison to baseline and prior visits
6. Surgical Planning: Documentation often directly supports surgical necessity and planning

Subjective Section (S)

In an ophthalmology SOAP note, the Subjective section captures the patient's chief complaint and ocular history, often requiring laterality specification and functional impact assessment.

Subjective Section (S) Components

1. Chief Complaint:

   • The primary reason for the visit with laterality
   • Example: "Blurred vision in right eye for 3 days" or "Routine diabetic eye exam"

2. History of Present Illness:

   • Onset, duration, progression of symptoms
   • Laterality (one or both eyes)
   • Associated symptoms (pain, photophobia, discharge, floaters)
   • Impact on daily activities (reading, driving, work)
   • Example: "68-year-old female with gradual onset of decreased vision OS over 6 months. Describes vision as 'cloudy.' More difficulty with night driving. Denies eye pain, redness, or flashes/floaters. No trauma."

3. Ocular History:

   • Previous eye conditions or diagnoses
   • Prior eye surgeries with dates
   • Current eye medications
   • Contact lens or glasses wear
   • Example: "PMOcH: Myopia since childhood. Bilateral cataract surgery 2015 with posterior chamber IOLs. Dry eye syndrome. No history of glaucoma, retinal detachment, or macular degeneration."

4. Systemic Medical History (Relevant to Eyes):

   • Diabetes and duration
   • Hypertension
   • Autoimmune conditions
   • Medications that affect eyes (steroids, hydroxychloroquine, tamoxifen)
   • Example: "PMH: Type 2 diabetes for 15 years (HbA1c 7.2%), hypertension, hyperlipidemia. Current medications: metformin, lisinopril, atorvastatin. No known drug allergies."

5. Family Ocular History:

   • Glaucoma, macular degeneration, retinal detachment
   • Age of onset if known
   • Example: "FH: Mother had glaucoma diagnosed at age 65. Father had macular degeneration."

6. Social History (As Relevant):

   • Occupation (especially for occupational eye hazards)
   • Smoking history (AMD risk factor)
   • Sun exposure
   • Example: "Retired accountant. Former smoker (quit 10 years ago, 20 pack-year history). Wears sunglasses regularly."

7. Review of Systems (Ocular and Related):

   • Pain, redness, discharge
   • Flashes, floaters, visual field defects
   • Diplopia, photophobia
   • Headaches
   • Example: "Denies eye pain, redness, discharge, flashes, floaters, or diplopia. No headaches."

Objective Section (O)

The Objective section documents measurable findings from the ophthalmology examination using specialized equipment and techniques.

Objective Section (O) Components

1. Visual Acuity (Distance and Near):

   • Document for each eye separately with correction status
   • Pinhole testing if vision reduced
   • Near vision when relevant
   • Example: "VA: OD 20/40 sc, 20/25 cc, PH 20/20; OS 20/50 sc, 20/30 cc, PH 20/25; OU 20/30 cc. Near: J2 OU with readers."

2. Pupils:

   • Size, shape, reactivity
   • Presence of relative afferent pupillary defect (RAPD)
   • Example: "Pupils: 4 mm in dim light, round, reactive to light and accommodation. No RAPD."

3. Extraocular Movements (EOM):

   • Full in all fields of gaze or specific limitations
   • Example: "EOM: Full OU, no nystagmus or strabismus. Cover test: orthophoric at distance and near."

4. Confrontation Visual Fields:

   • Screening test for gross defects
   • Example: "CVF: Full to finger counting OU" or "CVF: Inferior field defect OS"

5. Intraocular Pressure (IOP):

   • Measurement for each eye with method and time
   • Example: "IOP: OD 16 mmHg, OS 18 mmHg by Goldmann applanation at 2:00 PM"

6. Slit Lamp Examination:

   • Systematic anterior segment evaluation
   • Lids and lashes
   • Conjunctiva and sclera
   • Cornea
   • Anterior chamber depth and cells
   • Iris
   • Lens
   • Example detailed below

7. Dilated Fundus Examination:

   • Optic nerve (cup-to-disc ratio, color, margins)
   • Macula (foveal reflex, lesions)
   • Vessels (caliber, AV ratio, crossing changes)
   • Periphery (tears, holes, degeneration)
   • Vitreous
   • Example detailed below

8. Gonioscopy (when indicated):

   • Angle anatomy and grading
   • Pigmentation, peripheral anterior synechiae
   • Example: "Gonioscopy: Shaffer grade 3-4 OU, no PAS, moderate trabecular pigmentation"

9. Ancillary Testing (when performed):

   • OCT (retinal thickness, layer analysis)
   • Visual field testing (mean deviation, pattern)
   • Corneal topography
   • Fundus photos
   • Example: "OCT macula: Central subfield thickness 245 microns OD, 238 microns OS. No intraretinal or subretinal fluid. Intact ellipsoid zone."

Tips for Documenting Objective Findings in Ophthalmology

• Use Standardized Abbreviations: OD (right eye), OS (left eye), OU (both eyes), cc (with correction), sc (without correction), PH (pinhole)
• Be Specific with Location: Use clock hours for lesion location (e.g., "retinal tear at 10 o'clock periphery")
• Include Comparison Data: Reference prior measurements, especially for IOP and visual acuity
• Document Testing Conditions: Dilation drops used, lighting conditions, cooperation level
• Use Grading Systems: Nuclear sclerosis (1-4+), angle grading (Shaffer or Scheie), diabetic retinopathy staging
• Note Asymmetry: Document any differences between eyes prominently
• Include Negative Findings: "No neovascularization" is as important as positive findings

Assessment Section (A)

The Assessment section synthesizes subjective complaints and objective findings into diagnoses with laterality and severity.

Assessment Section (A) Components

1. Primary Diagnosis:

   • Specific diagnosis with laterality and staging/severity
   • ICD-10 code when relevant for billing
   • Example: "Senile nuclear cataract, bilateral (H25.13), moderate severity"

2. Secondary Diagnoses:

   • Other active ophthalmic conditions
   • Systemic conditions affecting eyes
   • Example: "Nonproliferative diabetic retinopathy without macular edema, bilateral (E11.329); Glaucoma suspect (H40.003)"

3. Clinical Reasoning:

   • Why this diagnosis explains the findings
   • Rule-outs considered
   • Progression since last visit
   • Example: "Visual symptoms consistent with cataract severity on exam. No evidence of other causes of vision loss. IOP controlled on current regimen."

4. Functional Impact:

   • How condition affects patient's daily life
   • Disability or impairment
   • Example: "Cataracts interfering with safe night driving and reading. Patient desires surgical intervention."

5. Risk Factors and Prognosis:

   • Factors affecting progression or treatment success
   • Expected outcome with treatment
   • Example: "Good surgical candidate. Diabetes well-controlled, reducing risk of post-op complications. Expected improvement to 20/25 or better following cataract extraction."

Plan Section (P)

The Plan section outlines the treatment approach, surgical planning, patient education, and follow-up schedule.

Plan Section (P) Components

1. Treatment Plan:

   • Medications with dosing, frequency, duration
   • Surgical recommendations
   • Conservative management options
   • Example: "Plan for phacoemulsification with posterior chamber IOL implantation OS. Schedule pre-operative testing including biometry for IOL power calculation."

2. Diagnostic Testing:

   • Additional tests ordered
   • Rationale for testing
   • Example: "Order optical biometry for IOL power calculation. Target slight myopia (-0.75 D) for reading preference."

3. Surgical Planning (when applicable):

   • Specific procedure
   • Laterality and timing
   • Target refraction
   • Lens selection
   • Example: "Phacoemulsification with monofocal IOL OS, schedule for 2 weeks. Discuss options: monofocal for distance vs. toric (minimal astigmatism) vs. premium IOL. Patient prefers standard monofocal."

4. Patient Education:

   • Instructions provided
   • Risks and benefits discussed
   • Informed consent
   • Example: "Discussed cataract surgery including risks (infection, bleeding, retinal detachment, PCO), benefits (improved vision, reduced glare), and alternatives (updated glasses, watchful waiting). Patient understands and wishes to proceed."

5. Medications:

   • Continue current medications
   • New prescriptions
   • Pre-operative or post-operative medications
   • Example: "Continue latanoprost 0.005% OU qhs. Will provide post-operative drops (prednisolone, antibiotic) after surgery."

6. Lifestyle and Activity Modifications:

   • Activity restrictions
   • UV protection
   • Diabetic control
   • Example: "Encouraged continued excellent diabetic control. Recommended UV-blocking sunglasses for AMD prevention."

7. Follow-Up Plan:

   • When to return
   • What will be monitored
   • Red flags to report
   • Example: "Post-operative day 1 visit scheduled. Follow-up in 1 week and 1 month. Call immediately for severe pain, vision loss, or increased redness."

8. Coordination of Care:

   • Referrals to other specialists
   • Communication with PCP about diabetic control
   • Example: "Will send cataract surgery report to Dr. Jones (PCP). Recommend continued annual dilated exams with optometrist for diabetic retinopathy screening."

Tips for Creating Effective Plans in Ophthalmology

• Specify Laterality: Always indicate which eye(s) for treatments and procedures
• Target Refraction: Document IOL power calculation goals for cataract surgery
• Include Measurements: OCT measurements, pachymetry values, K readings for planning
• Document Alternatives: Show informed decision-making by listing other options considered
• Timeline: Specify when interventions will occur (immediate, 2 weeks, 6 months)
• Risk Stratification: Note factors that increase surgical or treatment risks
• Compliance Considerations: Note patient factors affecting treatment adherence

AI-Assisted Documentation for Ophthalmology

Working with AI Scribes in Ophthalmology

AI-powered documentation tools can significantly reduce charting time while capturing specialized ophthalmology terminology. When using ambient AI documentation:

Speak Clearly During Exam:

• Verbalize all measurements: "Visual acuity right eye 20-40, left eye 20-60"
• State laterality explicitly: "Right eye IOP 16, left eye 18"
• Use full terms first, abbreviations after: "Cup-to-disc ratio 0.4 in both eyes"

Ophthalmology-Specific AI Considerations:

• Verify all numerical values (VA, IOP, pachymetry, OCT measurements)
• Confirm laterality (OD/OS) hasn't been reversed
• Review anatomical location descriptions (clock hours, zones)
• Check that grading systems are correctly captured (nuclear sclerosis 1-4+)
• Ensure systematic slit lamp findings are complete

Review Checklist for AI-Generated Ophthalmology Notes:

• ☐ Visual acuity documented with correction status for each eye
• ☐ IOP values recorded with method and time
• ☐ Slit lamp exam complete from lids to lens bilaterally
• ☐ Fundus exam includes all standard components
• ☐ Laterality correct throughout (OD/OS/OU)
• ☐ All numerical measurements verified
• ☐ Comparison to prior visit documented
• ☐ Surgical plans include target refraction and lens type
• ☐ Medication dosing and frequency accurate

Specialty-Specific Vocabulary AI May Misinterpret

Ensure AI correctly captures these ophthalmology terms:

• "Cup-to-disc" not "cup-to-disk"
• "Limbus" not "limus"
• "Shaffer grade" not "Schafer grade"
• "Neovascularization" not "new vascularization" (one word)
• "Ellipsoid zone" not "ellipsoidal zone"
• Clock hours (10 o'clock, not 10 o'clock)

Telehealth Considerations for Ophthalmology

Telehealth has significant limitations for ophthalmology given the specialized examination equipment required. However, certain encounters can be conducted remotely.

Telehealth-Appropriate Visits

• Post-operative check-ins for symptom assessment
• Medication management for glaucoma or dry eye
• Initial consultations before in-person examination
• Urgent triage (red eye, pain, vision changes)
• Follow-up for stable chronic conditions with recent exam data

Documentation Requirements for Telehealth

1. Technology Platform: Document video platform used
2. Visual Acuity: Patient-measured using app or Amsler grid
3. Exam Limitations: "Unable to perform slit lamp, IOP, or dilated exam via telehealth"
4. Image Review: Note any photos/images patient provided
5. Disposition: Document if in-person exam needed

Common Ophthalmology Conditions and Documentation Examples

Cataract

Key Documentation Elements:

• Lens opacity type and grade (nuclear, cortical, PSC)
• Visual acuity with best correction
• Functional impact (glare, night driving)
• Other causes of vision loss ruled out
• Surgical planning details

Glaucoma

Key Documentation Elements:

• IOP with time of measurement
• Cup-to-disc ratio with comparison to baseline
• Visual field results (MD, PSD, pattern)
• OCT RNFL thickness
• Angle assessment (gonioscopy)
• Medication regimen and adherence

Diabetic Retinopathy

Key Documentation Elements:

• DR staging (no DR, mild/moderate/severe NPDR, PDR)
• Specific findings (MAs, hemorrhages, exudates, NVD/NVE)
• Macular edema presence and location
• OCT central subfield thickness
• Previous laser or anti-VEGF treatment
• Diabetic control (HbA1c)

Age-Related Macular Degeneration

Key Documentation Elements:

• Type (dry vs wet)
• Drusen size and distribution
• Geographic atrophy if present
• Choroidal neovascularization on OCT/FA
• Visual acuity and impact
• Amsler grid distortion

Compliance and Legal Considerations

Medical-Legal Protection

Thorough ophthalmology documentation protects against liability:

• Pre-Operative Consent: Document risks, benefits, alternatives discussed
• Surgical Complications: Immediate documentation of intra-operative issues
• Informed Refusal: When patient declines recommended surgery or treatment
• Comparison Data: Previous exam findings to show progression
• Standard of Care: Documentation shows adherence to clinical guidelines

Billing and Coding Support

Ophthalmology documentation must support level of service billed:

• E/M Level: Complexity of examination and decision-making
• Surgical Necessity: Functional vision criteria for cataract surgery (typically <20/40 or significant glare disability)
• Testing Medical Necessity: Rationale for OCT, visual fields, angiography
• Modifier Usage: Document when procedures done bilaterally (-50) or staged
• Time-Based Coding: When using time for E/M, document total face-to-face time

Required Elements for Medicolegal Protection

1. Informed consent documentation for procedures
2. Visual acuity with best correction
3. Comparison to prior visit when available
4. Complications or adverse events immediately documented
5. Patient education and instructions provided
6. Follow-up plans and red flag symptoms reviewed