NextGen Knowledge Center

Document a Non-Laser Retinal Procedure

Workflow for documenting a non-laser procedure starts in the upper left of the Retina Office Procedures - Other - OPH template and flows down and across for each section.

  1. Access the Retina Office Procedures – Other – OPH template.
    The Retina Office Procedures - Other - OPH template opens.
  2. In the upper section of the template, document the following information:
    1. Click Category and select a category of surgery from the list:
      • Macula
      • Retina
      • Vitreous/Periph
    2. Click Diagnosis and select a diagnosis using the diagnosis search tool.
      The code associated with the selected diagnosis appears in the corresponding Code field.
    3. Click the Status field corresponding to the Diagnosis and select a status from the list that opens.
    4. Click the Anesthesia field and select a method of anesthesia from the list.
    5. Click the Procedure field and select a procedure from the list.
      • Cryopexy
      • Gas-fluid exchange
      • Paracentesis
      • Pneumatic retinopexy
      To enter a procedure not listed, select the top blank line and enter the text.
      The Code field associated with the Procedure field automatically displays the code. If a procedure was manually entered, click the Code field and type the appropriate code.
    6. To clear out the Diagnosis, Code, and Status fields, click the Clear button next to the Status field.
    7. To add the selected procedure diagnosis to the list of assessments for today's encounter, click Add to Today's Assessments.
    8. Indicate whether or not the procedure is Within 90 day PO period for same Tx and same eye by selecting No or Yes.
  3. Document consent for the procedure.
  4. Complete Pre-procedure care by selecting check boxes for appropriate items

    (These are required if the Joint Commission setting is selected on the Practice Configuration practice template.)

  5. Document the following general procedure information:
    1. Click the Goals field and select a laser indication from the list that opens. To select a value not listed, select the top blank line and type free text.
      The Treatment Eye list opens automatically.
    2. Select which eye the procedure is being performed on from the Treatment Eye list.
      The selected treatment eye appears in the Eye field. The Surgeon field automatically displays the provider currently selected for the encounter in the application toolbar.
    3. Click the Tech field and select a technician from your customized list of technician names. To select a name not listed, close the list and enter the text.
    4. Indicate the patient's Mood/Affect by selecting No or Yes.
    5. Indicate the patient's Orientation by selecting Oriented x3 or Abnormal.
    6. In the IOP section at the bottom of the template, review or document pre-operative IOP. Enter values for OD and OS, and click Save.
      Previously entered values appear in the grid and certain fields.
      The bottom of the Retina Office Procedures – Other – OPH template.

    7. In the Vital Signs section at the bottom of the template, review or document pre-operative vital signs.
  6. Document the procedure performed and its details:
    1. If performed, select the Pneumatic retinopexy check box and document the following details for the procedure.
      • Type of gas
      • Volume
      • Location
      • Indicate if Paracentesis was done by selecting No or Yes; if Yes, enter the volume of Fluid removed in mL.
    2. If performed, select the Cryopexy check box and document the Location by selecting Superior, Temporal, Inferior, or Nasal.
    3. If performed, select the Paracentesis check box and document the following details for the procedure.
      • Specimen sent to lab - select No or Yes.
      • Click the Fluid removed field and select or enter the volume in mL.
    4. If performed, select the Gas-fluid exchange check box and document the following details for the procedure.
      • Click the Type of gas field and select from the list that opens; enter a value not listed by selecting the top blank line and typing desired value.
      • Click the Volume field and select or enter the volume in mL.
      • To add any additional information, click the Notes field and enter free text.
    5. To add any additional procedure information, click Additional Procedure Notes, to open the Retina Office Procedure Note - OPH template. Click the large Note field and enter free text. Click Save & Close.
    The second page of the Retina Office Procedures – Other – OPH template.

  7. To review or document patient dilation and other eye drop medications administered to the patient on the Dilation/Other Medications - OPH template, click the Patient Dilation link. If the patient was not dilated, this can be documented, along with a reason for not doing so.
  8. If appropriate, select the check box to indicate Central retinal artery was examined and was well perfused after the procedure.
  9. Document complications. Select the No complications check box or use free text to document any complications in the adjacent field.
  10. Click the Time of procedure field. The current system time automatically appears.
  11. At the bottom of the template, document postoperative IOP and vital signs.
    1. In the IOP section, document post-operative IOP. Enter values for OD and OS, and click Save.
    2. In the Vital Signs section, document post-operative vital signs or select the Postop vitals waive by surgeon check box.
  12. Create drawings to document findings.
  13. Generate discharge instructions for the patient.
    1. Click the Discharge Instructions link to open the Discharge Instructions – OPH template.
      The Discharge Instructions - OPH template.

    2. Select one or more check boxes as appropriate to include corresponding instructions in the generated document.
    3. Click Save & Close to generate the document and exit the template.
    The Discharge Instructions document to give to the patient is generated.
  14. Document a return visit.
    1. In the Return visit section, schedule and place orders for any diagnostic tests and procedures to be performed.
    2. To select a timeframe for return to clinic, click the RTC field and select a timeframe from the list that opens. To enter a value not listed, select the top blank line and enter free text.
  15. To add this procedure to the Ocular History grid, click Add to Histories.
  16. When the procedure is completed, in the bottom right of the template, click Generate Note.

    A separate procedure note generates.