Built in Direct Collaboration with Practicing Ophthalmology Physicians

Ophthalmology Clinical Notes in Seconds

Dictate. Generate. Go home.

Built in direct collaboration with practicing ophthalmologists, ExamScribe handles the precision documentation of eye care — complete slit lamp findings, IOP measurements, fundus examination, and surgical planning notes. Documentation that captures your clinical findings with the specificity ophthalmology requires.

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ExamScribe — Ophthalmology Encounter
🎤 Your Voice Recording

"74-year-old female with primary open-angle glaucoma, here for follow-up. She's on latanoprost right eye and timolol both eyes. IOP today right eye 22, left eye 19. Target IOP is 15 or less. Visual fields last month showed progression in the right eye, new paracentral scotoma. OCT shows thinning of the RNFL inferiorly right eye. I'm going to add brimonidine to the right eye and refer for SLT. Cup to disc ratio right eye 0.8, left eye 0.7. Anterior segment clear both eyes."

📄 Generated Clinical Note
CHIEF COMPLAINT: Primary open-angle glaucoma follow-up — IOP above target, visual field progression HISTORY OF PRESENT ILLNESS: 74-year-old female with known primary open-angle glaucoma presenting for follow-up. Currently on latanoprost 0.005% OD QHS and timolol 0.5% OU BID. IOP above target bilaterally. Recent visual field testing demonstrated progression in the right eye with new paracentral scotoma. OCT confirms structural progression. OCULAR EXAMINATION: Visual Acuity: OD 20/40, OS 20/25 (with correction). IOP (Goldmann): OD 22 mmHg, OS 19 mmHg. Target IOP: ≤15 mmHg OU. Anterior Segment (Slit Lamp): Cornea clear OU. Anterior chamber deep and quiet OU. Lens: mild nuclear sclerosis OU. No rubeosis. Posterior Segment: OD: C/D ratio 0.8. Inferior RNFL thinning. No disc hemorrhage. Macula flat. Vessels normal caliber. OS: C/D ratio 0.7. Stable appearance. Macula flat. DIAGNOSTICS: Visual Fields (Humphrey 24-2): OD — new paracentral scotoma, MD -6.2 dB (worsened from -4.8 dB). OS — stable. OCT RNFL: OD — inferior RNFL thinning, below normal limits. OS — within normal limits. ASSESSMENT & PLAN: 1. POAG, OD — functional and structural progression on current regimen 2. Add brimonidine 0.2% OD BID to current regimen 3. Referral for selective laser trabeculoplasty (SLT) OD 4. Repeat visual fields and OCT in 4 months 5. Return in 6 weeks to assess IOP response to brimonidine

Built for How Ophthalmology Physicians Actually Work

Not a generic scribe with "Ophthalmology" added. Every template, every prompt, and every output was purpose-built for ophthalmology workflows.

Complete Ophthalmic Examination Documentation

Generates structured eye exam documentation covering visual acuity, IOP, anterior segment slit lamp findings, posterior segment examination, and ancillary testing — using proper ophthalmology terminology with laterality throughout.

Imaging and Testing Integration

OCT RNFL, visual field (Humphrey), fundus photography, fluorescein angiography, and biometry findings incorporated into clinical context — with progression analysis and treatment implications documented automatically.

Surgical Planning Documentation

Cataract surgery, glaucoma procedures, retinal surgery, and oculoplastics — surgical candidacy documentation with the specificity required for prior authorization and operative planning.

Ophthalmology-Specific Context Template Builders

AI can hear your words but cannot see your exam. These structured builders push real clinical findings to the AI in one click — eliminating hallucination and ensuring every note reflects what you actually did.

Glaucoma Management

IOP, target pressure, C/D ratio, RNFL OCT, visual field progression, medication/laser/surgical plan

Cataract Evaluation / Pre-Op

Visual acuity, lens grade, biometry, IOL selection, surgical candidacy, informed consent elements

Diabetic Eye Disease

DRSS level, macular edema, OCT-A findings, anti-VEGF response, laser history, systemic correlation

Age-Related Macular Degeneration

AMD stage, drusen characteristics, CNV activity, anti-VEGF injection documentation, OCT response

Retinal Detachment

Detachment extent, macula status, break location, surgical approach, post-op positioning

Dry Eye Disease

OSDI score, TBUT, Schirmer test, meibomian gland assessment, treatment ladder

Conjunctivitis

Type (bacterial/viral/allergic), discharge characteristics, corneal involvement, treatment, return precautions

Uveitis

Anatomic classification, cells/flare, KPs, posterior findings, etiology workup, steroid management

Keratoconus

Topography findings, Amsler-Krumeich stage, contact lens fitting, CXL candidacy

Strabismus

Deviation measurement, cover test, versions, amblyopia assessment, surgical candidacy

Integrated Compliance Engine

Ophthalmology Billing Requires Precise Documentation. Every Finding Matters.

Ophthalmology faces specific compliance challenges — the distinction between medical and routine eye exams, anti-VEGF injection documentation, and surgical candidacy requirements. ExamScribe's compliance engine ensures your notes support the services you're billing.

Medical vs. Routine Eye Exam Distinction

The distinction between a medical eye exam (92002/92004/92012/92014) and a routine refraction (92015) has significant billing implications. The engine checks that your note clearly documents the medical indication that supports the code billed.

Anti-VEGF Injection Documentation

Intravitreal injections (67028) require documented diagnosis, OCT findings, and clinical indication for each injection. The engine verifies your note contains the elements required for injection authorization and documentation.

Cataract Surgery Medical Necessity

Cataract surgery requires documented visual acuity, functional impairment, and failed conservative management. The engine checks that your pre-op note contains all elements required for surgical authorization.

Glaucoma Procedure Documentation

SLT, trabeculectomy, and MIGS procedures require documented IOP above target, medication failure, and clinical rationale. The engine verifies your note supports the procedure selected.

Visual Field and OCT Interpretation

Ancillary testing requires documented physician interpretation and clinical correlation. The engine checks that your note includes interpretation — not just raw values — to support the interpretation code billed.

Two-Pass AI Compliance Audit

Every note is analyzed for coding accuracy, documentation sufficiency, and payer-specific requirements. You receive a detailed gap report — reviewed and attested by you before any changes are made.

Three Steps. That's It.

Start generating notes in under a minute.

1

Record

Click record and speak naturally about the encounter — during the visit, after the visit, or just key findings. No special commands.

2

Generate

ExamScribe transcribes your recording and generates a complete, properly structured ophthalmology note with accurate specialty terminology in seconds.

3

Review & Export

Review the note, make any quick edits, and copy it into your EHR or export as PDF. Done.

Simple, Transparent Pricing

One plan. Everything included. No per-note fees.

Individual Physician
MonthlyAnnual Save $120/yr
$89/mo

billed annually ($1,068/yr)

  • 400 AI credits per month
  • All Ophthalmology template builders
  • Compliance audit engine
  • Document analysis & appeal letters
  • Voice-to-note in seconds
  • PDF & Excel export
  • HIPAA compliant — signed BAA included
  • 30-day free trial
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Your Patients' Data Is Sacred

Built with the same standard of care you bring to your patients.

HIPAA Compliant

  • Signed Business Associate Agreement
  • AES-256 encryption at rest
  • TLS 1.2+ in transit
  • SOC 2 Type II Azure data centers (US only)

Zero Data Sharing

  • Transcripts never used to train AI
  • No third-party data sharing — ever
  • Data never leaves US servers
  • You own your data — delete anytime

Automatic Protection

  • No audio recordings stored
  • Auto-delete on your schedule
  • Complete audit logging
  • Session timeouts enforced

Frequently Asked Questions

Does ExamScribe understand ophthalmology examination terminology?

Yes. ExamScribe produces complete eye examinations using proper ophthalmic language — slit lamp findings, IOP documentation, fundus examination, and ancillary test interpretation. Notes include laterality (OD/OS/OU) throughout.

Can ExamScribe handle high-volume ophthalmology practices?

Yes. Ophthalmology practices often see 40-60 patients per day. ExamScribe generates notes in the background while you move to your next patient — saving 2-3 hours of documentation time daily in a high-volume practice.

How does ExamScribe handle anti-VEGF injection documentation?

The AMD and diabetic eye disease templates capture OCT findings, disease activity, and injection indication. ExamScribe produces complete injection documentation with the specificity required for authorization and billing.

Can ExamScribe document cataract surgery pre-operative evaluations?

Yes. The cataract template captures visual acuity, lens grade, biometry results, IOL selection rationale, and surgical candidacy — producing a complete pre-operative note that meets authorization requirements.

Is my patient data used to train the AI?

Never. Your transcripts and patient data are never used to train AI models. All data is processed on HIPAA-compliant Azure servers in the US and auto-deleted on your schedule.

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