What should be included in a post-operative telephone follow-up note for a patient who is status post (s/p) cataract surgery?

Post-Operative Telephone Follow-Up Note for Cataract Surgery Patient

A comprehensive post-operative telephone follow-up note for a cataract surgery patient should include assessment of visual symptoms, medication compliance, signs of complications, and patient education regarding the recovery process. 1

Essential Components of the Telephone Follow-Up Note

Chief Complaint/Purpose of Contact

• Document the reason for telephone follow-up (routine post-operative day 1 check)
• Note the date of surgery and which eye was operated on

Subjective Assessment

• Visual symptoms:

  • Current visual acuity (patient's subjective description)
  • Presence of blurred vision
  • Visual changes since surgery
  • Light sensitivity/photophobia

• Pain assessment:

  • Presence, severity, and character of eye pain
  • Headache
  • Foreign body sensation

• Other symptoms:

  • Eye redness
  • Discharge or tearing
  • Nausea or vomiting
  • General condition and well-being

• Medication compliance:

  • Confirm patient is using prescribed eye drops correctly
  • Document any difficulties with administration
  • Review medication schedule (typically prednisolone acetate 1% four times daily for first 2 weeks) 1

Red Flags to Document

• Severe eye pain
• Significant decrease in vision
• Increasing redness
• Purulent discharge
• Photophobia
• Flashes or floaters
• Nausea/vomiting

Patient Education Provided

• Document instructions given regarding:
  • Proper eye drop administration technique
  • Activity restrictions (no heavy lifting, bending, eye rubbing)
  • Eye shield use (especially at night)
  • Importance of keeping follow-up appointments
  • When to call with concerns (worsening symptoms)

Assessment and Plan

• Overall assessment of recovery (uncomplicated vs. concerning)
• Confirmation of next scheduled in-person follow-up appointment
• Any medication adjustments made
• Need for urgent evaluation if concerning symptoms reported

Clinical Pearls for Telephone Follow-Up

1. Standardized approach: Using a structured questionnaire improves detection of complications and ensures consistency 2, 3

2. Complication detection: Be alert for symptoms suggesting serious complications requiring immediate evaluation:

   • Sudden vision loss (retinal detachment, endophthalmitis)
   • Severe pain with nausea/vomiting (acute IOP elevation)
   • Purulent discharge (infection)

3. Medication warnings: Remind patients about potential side effects of steroid eye drops, including elevated intraocular pressure with prolonged use 4

4. Documentation quality: Ensure thorough documentation of all symptoms reported, instructions given, and follow-up plan

5. Patient acceptability: Research shows high patient satisfaction with telephone follow-up after uncomplicated cataract surgery, with time-saving and convenience as key benefits 5, 3

Cautions and Limitations

• Telephone follow-up is appropriate only for uncomplicated cases and selected patients 3
• Some patients may be difficult to reach by telephone (9.2% unreachable in one study) 2
• Visual assessment is limited to patient self-reporting
• Consider earlier in-person evaluation for patients reporting concerning symptoms 1

Telephone follow-up has been shown to be a safe alternative to in-person day 1 post-operative visits in carefully selected patients, with significant benefits for both healthcare resource utilization and patient convenience 3.