Document a Gonioscopy Exam

NextGen® Ophthalmic Suite Help 2022.2

Document a Slit Lamp Exam

You can document a slit lamp exam in the following areas: In the Physical Exam panel, go to the Slit Lamp section. slit lamp exam panel For a more detailed exam, click the Slit Lamp link. Previosuly documented findings appear in the current enocunter fields. To copy the last exam, select the Copy last exam check box. To indicate that the exam findings are within normal limits, select the Slit Lamp WNL check box. Update the exam findings in the corresponding fields. To save the documented values as the default values, click the Quick Save, and enter a name for the template. This feature enables you to use the same values while documenting the same template during future encounters. To load the previously documented default values into the current template, click the Quick Load . For more information on the Quick Load and Quick Save functionalities, go to NextGen Healthcare Success Community, and download the latest Getting Started User Guide for NextGen® Adaptive Content Engine. Note: T

NextGen® Ophthalmic Suite Help 2022.2

Document a Posterior Exam

Ophthalmic providers can document Posterior exam findings in the Physical Exam panel. A more detailed Posterior exam can be documented on the Posterior Exam Detail template. You can document a posterior exam in the following areas. In the Physical Exam panel, navigate to the Posterior section. For a more detailed exam, click the Posterior link. Previosuly documented findings appear in the current encounter fields. Review and update the exam findings. To exclude an examination of the optic nerve: Select the Exclude check box in the Disc (ON) section. An Exclusions window appears. exclusions window Select an option in the Reason section. Select a specific reason from the list that appears, and click Save & Close. Data fields for Disc (ON) are hidden, and the selected reason for not performing an exam of the optic nerve appears. disc on section To save the documented values as the default values, click the Quick Save, and enter a name for the template. This feature enables you to use the

NextGen® Ophthalmic Suite Help 2022.2

Document an External Exam

On the LV Exam - OPT template, expand the Physical Exam panel. To copy the last documented external exam findings to the current exam fields, select the Copy last exam check box. Note: You must have access to use copy-forward. If all external exam findings are normal, select the appropriate External WNL check box for each eye. Exam parameter fields fill with normal default finding values. Enter the pupil size for Dim and Bright light for each eye. Document OD and OS findings as follows: Click Findings field, and select a value from the list. Abnormal findings appear in red font. Click the Modifier field, and select a value from the list. If OD and OS findings for a parameter are the same for both the eyes, click the arrows between the OD and OS fields to copy an entry from one eye to the other. Repeat the steps above for each exam parameter you want to document. To save the documented values as the default values, click the Quick Save, and enter a name for the template. This feature en

NextGen® Ophthalmic Suite Help 2022.2

Document a Physical Exam (Technicians/Assistants)

The following steps describe the general workflow for documenting findings for Ophthalmology physical exams. While there are differences in the parameters being documented for each exam, the process of entering the data in the exam section on the Physical Exam panel and on the individual exam detail templates is similar for many parameters of most exams. At the top of the panel, indicate the following for the patient: Mood/Affect – Select Normal or Abnormal. Orientation – Select Oriented x3 or Abnormal. Locate the data entry fields for the exam you wish to document on the panel. To document a more detailed exam, click the exam link to the left of the Physical Exam grids to open the corresponding detailed exam template. When the Physical Exam panel is on the Provider - OPH template, an exam link is also found in the exam data entry section on the panel. If the physical exam findings are normal, select the WNL check box for each eye as appropriate, OD and OS. Exam parameter fields corres

NextGen® Ophthalmic Suite Help 2022.2

Gonioscopy Exam

The detailed Gonioscopy exam is optional. Gonioscopy exam findings can be viewed or documented on the Gonioscopy – OPH template, which can be opened from three different places: Slit Lamp Exam Detail template - during technician/assistant and provider workflow Provider – OPH template – on the Physical Exam panel during provider workflow OPH Physical Eye Exam template – during provider workflow Note: When you make an entry on the Gonioscopy - OPH template causes Gonioscopy to appear in the list of billable procedures on the Finalize - OPH template. You must add a diagnosis code to the Gonioscopy procedure on the Finalize - OPH template. Parent topic: Physical Exams (Technicians/Assistants)

NextGen® Ophthalmic Suite Help 2022.2

Slit Lamp and Gonioscopy Exams

A Slit Lamp exam can be documented directly on the Physical Exam panel. A more detailed Slit Lamp exam can be documented on the Slit Lamp Exam Details - OPH template. Links to the Slit Lamp Exam Detail template appear in the External exam section of the Physical Exam panel and in the pane next to the physical exam grids. slit lamp exam details - oph template For providers, a link to the Gonioscopy – OPH exam template is also available. The detailed Gonioscopy exam is optional. Gonioscopy exam findings can be viewed or documented on the Gonioscopy – OPH template. Note: When you enter data on the Gonioscopy template, the system sends the Gonioscopy billing code to the Finalize - OPH tab where you can add a diagnosis code before submitting the code to the Superbill. Document a Gonioscopy Exam Ophthalmic providers can document the Gonioscopy exam on the Gonioscopy - OPH template. Document a Slit Lamp Exam Document a Posterior Exam Detailed Posterior Exam for Macula and Vessels Ophthalmolog

Document a Gonioscopy Exam

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