Document Patient Consent
- Access the Consent Forms – OPH template.
- Click the Consent by field to open a list of choices for who is giving consent: patient, parents, or guardian. To enter information not listed, select the top blank line and free text.
- Document indications.
- Click the first available Condition field.
The diagnosis search tool opens.
- On the left side, select the category of diagnoses to search.
- In the right-side list, highlight the diagnosis to be associated with the procedure and click Select.
The diagnosis search tool closes, and the diagnosis appears in the Condition field. A list for Eye opens.
- Select the eye the procedure is to be performed on from the list that opens.
- Repeat these steps to select all conditions to be associated with the procedure.
- Click the first available Condition field.
- Document the procedure.
- Click the first available Procedure field.
The procedure search tool opens.
- Type a few letters of the procedure or a word in the Description field and click Search.
If the proper name of the procedure is unknown, using the asterisk * symbol before and after the entry to search for that entry anywhere in the description.
- Highlight the procedure and click OK.
The procedure search tool closes, and the procedure appears in the Procedure field. A list for Eye opens.
- Select the eye the procedure is to be performed on from the list that opens.
- Repeat these steps to select all procedures to be performed.
- Click the first available Procedure field.
- Procedure date and Time fields default to the current system date and time.
- To change the date and time, click each field and select a new date and time.
- If the procedure is not scheduled yet, select the To be scheduled in the near future check box.
- Review lists with the patient:
- Standard Risks is a list of the standard risks for any procedure. Select the check boxes for items that apply.
- Specific Risks is a list of risks specific to Ophthalmology procedures. Select the check boxes for items that apply.
- Other risks can be entered by clicking the Other risks field and typing free text.
- Check List is a list of items to document prior to the procedure, including information given and the patient’s understanding of the procedure.
- Enter comments in the Comments field with free text.
- To task someone, click Send Task in the Tasking section to open the Tasking tool.
- Click Save & Close.
The Consent Form document generates automatically. Once the consent is generated, it can be printed, signed by the patient, and scanned back into the chart.