NextGen Knowledge Center

Document an Ophthalmic Postoperative Exam

Depending on the practice, documenting a post-op visit on the Postoperative Exam - OPH template may begin after Intake or after preliminary exams performed by a technician. Information previously documented for the encounter appears in the corresponding data fields on the Postoperative Exam - OPH template. This information can be reviewed and updated as appropriate.
  1. Review and update the procedure information in the General Information section at the top of the template. Document the following details for each procedure, as appropriate:
    Read-only date fields across the top display the date each exam was most recently performed and documented including, Dilated exam, Gonioscopy, OCT/HRT for optic nerve, and Visual Fields.
    postoperative exam - oph template

  2. Enter the Reason for Visit.
  3. Enter the Visual Acuity and click Save.
  4. Record the (Intraocular Pressure)IOP and click Save.
  5. Document the External exam.
  6. Document the Slit Lamp exam.
  7. If appropriate, document details for the intraocular lenses (IOL) that were implanted during cataract surgery in the IOL Information OD and IOL Information OS sections.
    iol information os section

  8. Enter Posterior exam findings.
  9. Select Patient Instructions/Advice and instructions.
    A paragraph builds in the large text field as selections are made.
  10. Medications and instructions can be documented for the patient in the Medications section.

    For repetitive instructions, My Phrases functionality can be used.

    1. To add or update medications, click the Add/Update button to open the Medication module.
    2. To document medication reconciliation, click the Reconcile button.
      medication section

  11. Providers can enter notes that do not appear in documents in the Internal Physician Notes. Click the Save application toolbar button to save to the grid.
    internal phsician notes section

  12. Document an impression, plan, and return to the clinic in the Impression and Plan section.