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Ophthalmology clinicians document faster with structured session workflows that match how they actually examine, operate, and treat. See All Features

Ophthalmology Clinical Documentation

Five sub-specialties. One structured session workflow. Structured examination forms for visual acuity, IOP, slit-lamp, and fundus. Surgical documentation for cataract IOL calculations, LASIK parameters, and intravitreal injection records. OCT and fundus images linked directly to the session — all inside one clinical interface.

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Generic clinical notes don't have fields for IOL calculations, RNFL thickness, or intravitreal drug dosage. An ophthalmology clinical session isn't a free-text note with a few measurements added. A cataract session requires biometry results, IOL selection, and phacoemulsification technique documentation. A glaucoma session requires IOP, disc grading, and OCT RNFL values structured for longitudinal comparison. A retina session requires intravitreal drug name, batch, dose, and injection site per eye. WIO CLINIC's ophthalmology session interface provides structured forms for each sub-specialty — General Exam, Cataract, Glaucoma, Retina, and Refractive Surgery — with every field clinicians actually fill in.

Visual Field Test Records

Visual field test results are stored with each glaucoma session and graphed across time — mean deviation, pattern standard deviation, and reliability indices are captured per test, enabling progression analysis without manual data extraction from separate perimetry software.

Glaucoma Medication Management

Active glaucoma medications — prostaglandin analogues, beta-blockers, carbonic anhydrase inhibitors, combination drops — are recorded per patient alongside the IOP readings they are managing. Changes to medication are logged with date and clinical rationale for the complete treatment history.

Pre-op Checklist Completion

Surgical pre-operative checklists are completed and signed off within the session — biometry confirmed, consent obtained, allergies checked, anaesthetic plan agreed. Each checklist item is timestamped, creating a verifiable pre-operative safety record linked to the surgical session.

Real-Time Record Updates

Every measurement, finding, and prescription entered in the session updates the patient record immediately — IOP trends, visual acuity timelines, and medication histories reflect the current session the moment it is saved, so any clinician opening the record sees current data.

Structured Examination Forms

Visual acuity (corrected and uncorrected, per eye), intraocular pressure, slit-lamp findings, anterior and posterior segment, and fundus documentation are captured in dedicated structured fields — not buried in free text — enabling accurate data retrieval and longitudinal trend analysis

Examination

Structured, not free text

Surgical Session Documentation

IOL power calculations, lens opacity grading, phacoemulsification technique and parameters, LASIK ablation profile, PRK and SMILE surgical settings, ICL vault measurements, and intravitreal injection records — each surgical session type captures the data its sub-specialty requires

Surgery

Sub-specialty specific fields

Documentation time per session cut from 15 min to 4 min

"Before, our glaucoma consultations meant dictating into a generic note and hoping someone entered the IOP correctly. Now each field has its place — visual field, RNFL, disc ratio, medication — and the trend graph updates the moment I save. My registrar spends the session with me, not typing."

Dr. Katarzyna Wiśniewska

Consultant Ophthalmologist

Sub-Specialty Module Switching

The right session form opens automatically

When a session opens from a scheduled appointment, the system loads the correct sub-specialty form based on the appointment type — a cataract follow-up opens the cataract module, a glaucoma check opens the glaucoma module. All five sub-specialty forms remain accessible within the session for cases where the consultation reveals conditions outside the booked reason. General Eye Examination is available as the default baseline for all new presentations, covering the full 95%-coverage exam before sub-specialty referral.

OCT & Imaging Integration

Images in the session, not attached to an email

OCT scans and fundus photographs are linked directly to the clinical session at the point of capture — not uploaded separately and not stored in a disconnected imaging system. Within the session, side-by-side comparison views show the current scan against prior sessions from the patient record, enabling in-consultation progression assessment. Images are indexed by date, session, and eye, so any past scan is retrievable in seconds without navigating away from the clinical interface.

Digital Consent & Audit Trail

Signed before the procedure, stored in the record forever

Procedure-specific consent forms are generated from versioned templates and presented for e-signature and timestamp binding before each surgical session — cataract, LASIK, intravitreal injections, and vitrectomy each have dedicated consent documents. Patients sign on a tablet in clinic or via their phone before arrival. Every signed document is stored in the patient record with a complete audit trail. Every clinical action in the session — examination recorded, image captured, consent signed, prescription issued — is timestamped and attributed, creating a tamper-evident record that protects the practitioner in any regulatory or medico-legal review.

The complete ophthalmology session workflow

From examination to discharge instructions

Medication Prescribing

Issue prescriptions for topical and systemic medications directly from the session — with a drug database covering ophthalmic drops, oral medications, and injectables. Allergy alerts and contraindication flags surface at prescribing, and prescription history is accessible in every subsequent session.

Aftercare Instructions

Send procedure-specific aftercare instructions by SMS or email at session close — post-operative drop regimens, activity restrictions, warning signs, and follow-up timing. Instructions are procedure-matched and branded to the clinic, and their delivery is logged in the session audit trail.

Session Timeline & Audit

Every action in the session is timestamped — examination recorded, imaging captured, consent signed, prescription issued, invoice generated. The complete, immutable session timeline protects the practitioner and the clinic in any clinical governance, insurance, or regulatory review.

Security & Compliance

Industry Recognition

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