NextGen Knowledge Center

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.

  1. At the top of the panel, indicate the following for the patient:
    1. Mood/Affect – Select Normal or Abnormal.
    2. Orientation – Select Oriented x3 or Abnormal.
  2. 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.

  3. If the physical exam findings are normal, select the WNL check box for each eye as appropriate, OD and OS.
    Exam parameter fields corresponding to the selected check box automatically fill with normal default finding values.
  4. To copy-forward exam findings from the last documented exam to the current exam, select the Copy last exam check boxes found in each exam section and on the individual physical exam detail templates, as appropriate.

    After you have copied-forward values from the last time the exam was documented, you can make updates and changes to findings as necessary for today’s encounter.

  5. Document individual physical exam findings for OD (right eye) for each parameter as appropriate:
    1. Enter a finding - Click the first finding field for a parameter and select a value from the list. Abnormal findings display in red font.
    2. Enter a finding modifier - Click the corresponding second field for a parameter and select a value from the list.
    3. For many parameters, if OD and OS findings are the same, use the left and right arrows corresponding to the parameter between the fields for OD and OS eyes.
      • Left arrow – copies the finding and its modifier from the OS eye to the OD eye
      • Right arrow – copies the finding and its modifier from the OD eye to the OS eye
    4. To clear a row of findings and modifiers for a parameter for OD and OS, click the corresponding Clear button on the right.
      All fields for OD and OS in the row are cleared.
    5. Repeat for each exam parameter you want to document.
  6. If appropriate, follow step 5 to enter physical exam findings for OS (left eye).
  7. If you have finished documenting findings on the detailed exam template, click Save & Close.