Ophthalmology Formal Report Writing

---
name: ophthalmology-formal-report-writing
description: |
  Write formal reports as a ophthalmologist that stand up to scrutiny from any reader.
  TRIGGERS - Use when a ophthalmologist needs a formal report writing for patients with eye conditions and vision problems in an eye hospital clinic and theatre.
category: Ophthalmology
license: MIT
version: 1.0
---
# Formal Report Writing — Ophthalmology

Write formal reports as a ophthalmologist that stand up to scrutiny from any reader. The deliverable is a report template with structure, evidence standards and review steps.
This skill is written for a ophthalmologist working with patients with eye conditions and vision problems in an eye hospital clinic and theatre.

## When to use
- You are a ophthalmologist preparing, delivering or reviewing this part of your work in an eye hospital clinic and theatre.
- You need a defensible, repeatable approach that produces a report template with structure, evidence standards and review steps.
- A colleague, auditor or client asks how this was done and what evidence supports it.

## Key Concepts
| Term | Meaning |
|------|---------|
| Visual acuity | the sharpness of vision, often recorded as a fraction |
| OCT | a scan showing cross-sections of the retina |
| Glaucoma | optic nerve damage often linked to raised eye pressure |

## Workflow
1. **Step 1** - Establish the report's purpose, audience and deadline before writing; gather source material from visual acuity charts
2. **Step 2** - Structure: summary, background, method, findings, analysis, recommendations — in that order
3. **Step 3** - Write findings factually and separately from opinion; label professional judgement as judgement
4. **Step 4** - Support key points with evidence and with cataract surgery outcomes where outcomes are claimed; acknowledge limitations openly
5. **Step 5** - Proofread for accuracy and tone, check names, dates and figures twice, and consider missed glaucoma progression before release

## Profession-Specific Components
| Component | Details for Ophthalmology |
|-----------|-------------------------------|
| Core documentation | visual acuity charts; OCT scans; operation notes; refraction records |
| Core tools & equipment | slit lamps; OCT scanners; phacoemulsification machines; visual field analysers |
| People involved | patients with eye conditions and vision problems; the ophthalmologist; colleagues and other services in an eye hospital clinic and theatre |
| Primary record | visual acuity charts — keep it current, dated and attributable |

## Output Format
**Context:** [Situation in an eye hospital clinic and theatre] | **Objective:** [What this must achieve] | **Audience:** [patients with eye conditions and vision problems and other stakeholders]

The finished output is a report template with structure, evidence standards and review steps, structured as:
1. Summary of position and evidence
2. Detail, following the workflow above
3. Decisions, actions, owners and dates
4. Review point and escalation route

### Action Plan
1. **Immediate:** Confirm scope, consent and the evidence available in visual acuity charts.
2. **Short-term:** Complete the workflow steps and record outcomes against cataract surgery outcomes.
3. **Medium-term:** Review results, close actions, and update local procedures in an eye hospital clinic and theatre.

## Success Metrics
| Metric | Target | Method |
|--------|--------|--------|
| cataract surgery outcomes | Agree a local target and track the trend | Measured from visual acuity charts and reviewed on a set cycle |
| clinic waiting times | Agree a local target and track the trend | Measured from visual acuity charts and reviewed on a set cycle |
| post-operative infection rate | Agree a local target and track the trend | Measured from visual acuity charts and reviewed on a set cycle |
| visual acuity improvement | Agree a local target and track the trend | Measured from visual acuity charts and reviewed on a set cycle |

## Guardrails & Quality Checks
- Never let this happen: missed glaucoma progression.
- Never let this happen: endophthalmitis after surgery.
- Never let this happen: wrong lens implant.
- Work only within the competence and authority of a ophthalmologist; escalate or refer anything beyond it.
- Record facts and observations, not speculation, and keep records confidential to an eye hospital clinic and theatre's rules.
- Verify names, dates, figures and measurements twice before anything is issued or signed off.
- Use only real, verified information from the case in hand — never invent results, credentials or evidence.

## Example (illustrative)
A ophthalmologist in an eye hospital clinic and theatre applies this workflow for patients with eye conditions and vision problems: they open
visual acuity charts, work through the five steps using slit lamps, and close by recording
the outcome against cataract surgery outcomes and agreeing the next review date. (Illustrative example only —
replace with the real details of the case in hand.)