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.
Access the Retina Office Procedures – Other – OPH template.
The Retina Office Procedures - Other - OPH template opens.
In the upper section of the template, document the following information:
Click Category and select a category of surgery from the list:
Macula
Retina
Vitreous/Periph
Click Diagnosis and select a diagnosis using the diagnosis search tool.
The code associated with the selected diagnosis appears in the corresponding Code field.
Click the Status field corresponding to the Diagnosis and select a status from the list that opens.
Click the Anesthesia field and select a method of anesthesia from the list.
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.
To clear out the Diagnosis, Code, and Status fields, click the Clear button next to the Status field.
To add the selected procedure diagnosis to the list of assessments for today's encounter, click Add to Today's Assessments.
Indicate whether or not the procedure is Within 90 day PO period for same Tx and same eye by selecting No or Yes.
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.)
Document the following general procedure information:
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.
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.
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.
Indicate the patient's Mood/Affect by selecting No or Yes.
Indicate the patient's Orientation by selecting Oriented x3 or Abnormal.
Previously entered values appear in the grid and certain fields.
In the Vital Signs section at the bottom of the template, review or document pre-operative vital signs.
Document the procedure performed and its details:
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.
If performed, select the Cryopexy check box and document the Location by selecting Superior, Temporal, Inferior, or Nasal.
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.
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.
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.
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.
To add this procedure to the Ocular History grid, click Add to Histories.
When the procedure is completed, in the bottom right of the template, click Generate Note.
