NextGen Knowledge Center

Document an Ophthalmic Physical Exam

The following steps describe the general workflow for documenting findings for the ophthalmic physical exams. While there are differences in the parameters being documented for each exam, the process of entering the data into the exam section on the Physical Exam panel or on the individual exam detail templates is similar for many parameters of most exams.

Findings documented by the technician appear in the exam fields and the grids.

  1. In the Physical Exam panel, select a value for Mood/Affect and Orientation.
  2. Do one of the following:
    • Document the exams in the data fields in the panel.
    • Click the exam link in the left pane of the OD and OS grids to open a detailed exam template.
  3. If all findings for a physical exam are normal, select the WNL check box.

    Exam parameter fields corresponding to the selected check box automatically fill with the normal default values.

  4. Click the Copy last exam check boxes to copy the last documented exam.
  5. Click the Copy Past Exam link to copy-forward physical exam findings from a selected previous encounter.
  6. Enter OD and OS findings.
  7. To copy the findings from one eye to the other, click the left and right arrows between the fields.
  8. To refresh the grid with the documented findings, click the Refresh button.