Patient: [Patient Name]
Date: [Date of Encounter]
Chief Complaint:
Eye pain (sharp, gritty, foreign body sensation)
Light sensitivity (photophobia)
Tearing
Blurred vision (may be present)
History of Present Illness:
Onset and duration of symptoms
Cause of injury (scratch, foreign object, unknown)
Previous corneal abrasions
Past Medical History:
Contact lens use (current or past)
History of eye surgeries or injuries
Underlying eye conditions (dry eye syndrome, recurrent corneal erosions)
Social History:
Occupational hazards (dust, metal exposure)
Hobbies and activities (potential for eye injury)
Medications:
Current medications (eye drops, ointments)
Allergies (medications, topical agents)
Ocular Exam:
Visual acuity (Snellen chart, record for each eye)
External examination:
Lids (lacerations, swelling)
Conjunctiva (injection, hyperemia)
Cornea:
Presence of corneal abrasion (location, size, depth)
Seidel sign (negative or positive – indicates perforation) – if applicable
Corneal fluorescein staining (positive staining confirms abrasion)
Intraocular pressure (IOP) – if indicated
Assessment:
Confirmed corneal abrasion
Severity of abrasion (superficial, partial thickness, full thickness) – depends on depth
Risk factors for complications (infection, delayed healing)
Underlying conditions contributing to abrasion (dry eye, contact lens use)
Plan:
Treatment:
Topical antibiotic ointment or drops to prevent infection
Pain relievers (over-the-counter) for discomfort
Cycloplegic eye drops (to relax ciliary muscle and reduce pain) – may be used
Eye patching (briefly to promote healing) – consider for larger abrasions
Patient education on:
Proper eye hygiene (avoid rubbing)
Importance of using prescribed medications
Signs and symptoms of infection (worsening pain, redness, purulent discharge)
Avoiding contact lens wear until healing is complete
Follow-up:
Schedule for re-evaluation to monitor healing and assess for complications (usually within 1-2 days)
Prognosis:
Most corneal abrasions heal within 1-3 days with proper treatment.
Discuss the expected course of healing and potential complications (infection, scarring).
Notes:
Include any additional observations or concerns, such as patient’s understanding of instructions, pain control, and potential need for referral to an ophthalmologist (complex cases, suspected perforation, slow healing).