ScribeMDPro

Ophthalmology

Ophthalmology notes as detailed as an eye exam

Visual acuity, IOP, slit lamp, dilated fundus — ScribeMDPro captures the full ophthalmic exam.

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Ophthalmology carries a documentation burden shaped by high visit volume, imaging-heavy workups and a very specific exam vocabulary. Visual acuity is called out per eye and per correction condition; intraocular pressures are quoted numerically; slit lamp and dilated fundus exams have standard formats. ScribeMDPro was configured with ophthalmology-native templates that capture the standard VA/IOP/exam structure, populate imaging review from what the clinician says aloud, and handle surgical planning discussions the way ophthalmologists actually document them. The template supports both comprehensive and subspecialty (retina, glaucoma, cornea) workflows.

Documentation challenges we solve

  • Standardized VA / IOP / slit lamp / fundus format is easily disrupted by ambient dictation
  • Imaging-heavy workup (OCT, VF, fundus photos) requires clean review documentation
  • Surgical planning conversations must be captured for consent and continuity
  • Subspecialty visits (retina, glaucoma, cornea) each have distinct expected content

What clinicians gain

  • Standard ophthalmology exam template with per-eye VA, IOP, slit lamp and DFE sections
  • Imaging review section structured by modality
  • Subspecialty templates for retina, glaucoma, cornea and oculoplastics
  • Pre-operative planning and consent conversations preserved verbatim

How it works

  1. Step 1
    Start ambient capture

    Open ScribeMDPro before the ophthalmology encounter and start recording — the patient never has to talk to a device.

  2. Step 2
    Focus on the patient

    Conduct your normal history and exam. Call out per-eye VA, IOP and exam findings as usual — the AI populates the standard ophthalmology template.

  3. Step 3
    Auto-drafted note

    A structured SOAP note appears seconds after the visit ends, formatted for your specialty.

  4. Step 4
    Review, sign, export

    Edit inline, copy to your EMR, download as PDF, or push through supported integrations.

Example SOAP output

S: 68yo F with slowly worsening central vision OU, worse OD. History of dry AMD.
O: VA OD 20/60 sc, OS 20/30 sc. IOP OD 14, OS 15. SLE: mild NS 2+ OU. DFE: OD drusen with new SRF suspicious for CNV; OS drusen without SRF. OCT OD confirms subretinal fluid.
A: Conversion to wet AMD OD.
P: Discussed anti-VEGF injection with patient. Consented and scheduled bevacizumab OD next week. Continue AREDS2. RTC 1 week post-injection.

Illustrative only. Clinicians retain final responsibility for the record.

Frequently asked questions

Does it capture per-eye VA and IOP correctly?

Yes. Per-eye values are captured as discrete fields, not merged into a single line.

How does it handle imaging review?

OCT, VF, fundus photo review is structured by modality with key findings and comparison to prior when discussed.

Are subspecialty templates supported?

Retina, glaucoma, cornea, oculoplastics and pediatric ophthalmology have specialty-tuned templates.

What about optometry practices?

Optometry workflows are supported using the same exam template with minor label adjustments.

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