Workflow for documenting a laser procedure starts in the upper left of the Retina Office Procedures - Laser - OPH template and flows down and across for each section.
Access the Retina Office Procedures – Laser – OPH template.
Document consent for the procedure.
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 free text.
The Code field associated with the Procedure field automatically displays the code. If a procedure was manually entered, click the Code field and manually type in 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.
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:
Indicate whether or not the procedure is Within 90 day PO period for same Tx and same eye by selecting No or Yes.
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 type free text.
In the IOP section, document pre-operative IOP. Enter values for OD and OS, and click Save.
Previously entered values appear in the grid and certain fields.
Indicate the patient's Mood/Affect by selecting No or Yes.
Indicate the patient's Orientation by selecting Oriented x3 or Abnormal.
In the Vital Signs section, document pre-operative vital signs.
Document the laser procedure and its details:
In the Laser TX section, select the check box corresponding to the appropriate laser treatment.
Selecting a Laser TX (laser treatment) check box causes other laser detail fields to automatically display default values corresponding to the selected treatment. You can manually change or add laser and treatment details. When PDI treatment is selected, additional fields appear for recording details for Visudyne use and J code billing. Additional details that fill in automatically include:
Lens system
Laser Type
Shots
Power
Duration
Spot size
Treatment return (TX Return)
Comfort
Notes
Generate a Note by selecting appropriate check boxes in the Laser Tx and Laser Type sections.
Selecting check boxes in the Laser Tx and Laser Type sections causes information to appear in the laser settings fields and begins to generate a note in the Notes field. You can add additional information to the note.
If appropriate, you can temporarily darken your computer's screen.
To darken your computer's screen, click Black Screen.
Your computer screen appears black with a small OK button in the lower right corner.
To exit dark mode, in the lower right corner, click OK.
Your computer screen returns to a bright display, and you can continue with your workflow.
To add this procedure to the Ocular History grid, click Add to Histories.
Generate discharge instructions for the patient.
Click the Discharge Instructions link to open the Discharge Instructions – OPH template.
Select one or more check boxes as appropriate to include corresponding instructions in the generated document.
Click Save & Close to generate the document and exit the template.
The Discharge Instructions document to give to the patient is generated.
Note: Only one document with discharge instructions can be generated for an encounter.
To select a time-frame for return to clinic, click the RTC field and select a time-frame from the list that opens. To enter a value not listed, select the top blank line and enter the text.
