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.
- 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.
- Enter the Reason for Visit.
- Enter the Visual Acuity and click Save.
- Record the (Intraocular Pressure)IOP and click Save.
- Document the External exam.
- Document the Slit Lamp exam.
- 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.
- Enter Posterior exam findings.
- Select Patient Instructions/Advice and instructions.
A paragraph builds in the large text field as selections are made.
- Medications and instructions can be documented for the patient in the Medications section.
For repetitive instructions, My Phrases functionality can be used.
- To add or update medications, click the Add/Update button to open the Medication module.
- To document medication reconciliation, click the Reconcile button.
- 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.
- Document an impression, plan, and return to the clinic in the Impression and Plan section.
