NextGen Knowledge Center

Document a Contact Lens Fitting and Evaluation Visit

Depending on the practice, workflow on the Contact Lens Evaluation - OPH template may begin after intake or after preliminary exams performed by a technician. Any information previously documented during the encounter appears in the corresponding data fields on the Contact Lens Evaluation - OPH template. This information can be reviewed and updated as appropriate.
  1. In the Reason for Visit panel, the provider reviews the technician's documentation, makes updates, and signs-off on the HPI information.
  2. In the Visual Acuity panel, enter exam findings or review and update previously documented results.
    visual acuity panel

  3. In the General Information panel, enter or review and update the patient information related to wearing contact lenses.
    general information panel

  4. In the Contact Lens History section, review and select the current contact lens prescription from the grids.
    contact lens history panel

    The prescription values appear in the fields of the Current Contact Lens Prescription section.
  5. In the Current Contact Lens Prescription section, review and make any adjustments and changes needed to the prescription for the contact lenses that the patient is currently wearing.
    1. For each of the following, you can document the exam and review previously documented findings.
      • Auto Refraction and/or Manifest Refraction
      • Auto-keratometry and/or Manual Keratometry
      • Slit Lamp Evaluation
    2. After making changes to the prescription, select the Copy to CL RX1 check boxes for each eye to copy the adjusted prescription to the RX1 fields in the Contact Lens Prescription section.
      contact lens prescription section

  6. In the Contact Lens Fit Analysis panel, a detailed fit analysis can be performed and documented for the adjusted current contact lens prescription.
    1. Select the Copy from Current check boxes for each eye to be analyzed.
      The prescription from the Current Contact Lens Prescription section is copied to the fields in the Contact Lens Fit Analysis panel for the selected eyes.
      contact lens fit analysis panel

    2. Prescription details can be further fine-tuned with additional adjustments and changes based on findings for Visual Acuity and Slit Lamp evaluation of lens fit.
    3. To clear the data fields in this section so that you can begin again, click Clear All.
    4. Click Add To Grid.
    5. To select a contact lens prescription to prescribe after completing Fit Analysis, select the option CL Rx1 or CL Rx2 above the grid for each eye, then select a row in the grid to copy its values to the prescription fields for CL Rx1 or CL Rx2 in the Contact Lens Prescription section for that eye.
      contact lens prescription section

  7. In the Contact Lens Consent section, do the following:
    • Select Paper Copy or Digital Copy.
    • Click Add, and then click Generate Consent.
  8. In the Contact Lens Prescription section, select the final details for the prescription and print the prescriptions to give to the patient.
    1. Select the option to indicate whether this is a trial or final prescription.
    2. Enter an Expiration Date, Replacement Schedule, Special designs and remarks, and Comments.
    3. To clear the data fields for a prescription, click the Clear All for that prescription.
    4. To print a prescription, click Print RX1 or the Print RX2, depending on which prescription you want to print. A prescription for trial lenses does not print since the practice usually dispenses them.
      printing prescription in contact lens prescription section

  9. In the Lens(es) Dispensed/To Be Ordered section, enter additional instructions for the patient and for the order, select your billing code(s), and generate the chart note.
    1. For the contact lens prescription being issued for the patient today, document the lenses dispensed and/or to be ordered.
    2. Enter any additional instructions for wearing and care for the patient and for the order.
    3. Enter the number of lenses dispensed for each eye, for trial lenses and/or final lenses.
    4. Select the codes for Contact Lens Fit Code.
  10. Click Generate Note.
  11. To open the Assessment/Plan – OPH template, click Assessment & Plan.