Complete the Ophthalmology Provider Workflow
For most office visit encounters in general Ophthalmology, the following is a basic outline of the workflow for the provider portion of the visit.
- To review historical information of the patient, go to the Home Page – OPH template.
- Go to the Provider – OPH template to document the provider's portion of the encounter.
Note: For certain encounters, there are specific single-page visit templates, such as Postoperative Exam – OPH.
- Select the Provider Summary link to review patient information for today's encounter.
- Select the Eye Summary link to view current and historical patient findings in a grid.
- Expand the General panel to review general patient information, the Health Monitor, and Internal Physician Notes.
- Expand the Orders panel to review, update, and add orders.
- Expand the Medications panel to review or update medications and perform medication reconciliation, if appropriate.
- Expand the Reason for Visit panel to review the technician conversation, makes any updates, and sign-off on the HPI details.
- Expand the Visual Acuity/Lensometry/Refraction panel to review test results or perform testing.
- In the Physical Exam panel, you can perform additional exams as appropriate and document results; record IOP measurements and Pachymetry readings; document drawings using the links in the panel that open images for the Ophthalmology Drawing Module.
- Use the links in the Additional Navigation section to open other templates, as needed.
- To generate the chart note, click Generate Note.
- Select the NG Mobile link to open the NG Mobile Dictation template to view the narrative data.
- Go to the Assessment/Plan – OPH template to document the assessment and plan.
- Expand the A/I/P panel to document assessment, impression, and plan.
- Expand the Internal Physician Notes panel to enter physician notes that you do not want to appear in the patient documents.
- Expand the Orders panel to review, update, and place orders.
- Go to the Finalize – OPH template to finalize coding and billing.
- Go to the Diagnosis panel to add or update the assessment or link a diagnosis to a procedure.
- In the Procedure Billing panel, you can submit billing for procedure-only visits.
- In the Medical Decision Making/Counseling panel, select the medical decision making level and/or enter the total Time of the visit.
- In the EM Code panel, you can calculate and submit the Evaluation and Management (E&M) Code; or select Eye Codes.
- To select a SNOMED visit type, click the SNOMED Visit Type (optional) link.
- Click the Fee Ticket button to generate the fee ticket.