NextGen Knowledge Center

Document a Postoperative Exam Impression and Plan

You can document an impression, plan, and return to clinic details in the Impression and Plan section of the Postoperative Exam – OPH template.

  1. Select the procedure to document by selecting the option Status Post Procedure 1 or Status Post Procedure 2. (Each procedure is documented separately.)
  2. Click the Dx Description field and select a diagnosis from the diagnosis search tool.
    The code associated with the diagnosis appears in the Code field.
  3. If applicable, click the Scribe field and select the scribe.
  4. To document any postoperative complications necessitating additional surgery within 30 days after cataract surgery, click the Post-op Complications link to open the Cataract Post-Op Complications template.
  5. Document an impression by selecting check boxes for any post-op impression details that apply.
    A paragraph builds in the large Impression text field as selections are made. After selecting check boxes, additional impression details can be typed in the text field using free text and My Phrases.
  6. Enter plan details by typing free text in the large Plan text field and by using My Phrases.
  7. Document return to the clinic by clicking the Return to clinic field and select from serial lists or use My Phrases.
    impression and plan template

  8. Click Add to Grid to save impression, plan, and return to clinic details to the Impression/Plan Summary grid.
    If you want to begin again, click the Clear All button to clear out the data fields in this section.
    impression/plan summary template

  9. If applicable, repeat steps 1- 8 to document the impression and plan for the second procedure.