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.
