External Exam

NextGen® Ophthalmic Suite Help 2022.2

Physical Exam Elements Documented by Technicians/Assistants

The following physical exam elements are found on the Physical Exam panel of the Prelim Exam template and are documented by technicians or assistants: Mood/Affect - section on the Physical Exam panel. Orientation - section on the Physical Exam panel. External exam - section on the Physical Exam panel and a link to the OPH External Exam Detail template Slit Lamp exam - section on the Physical Exam panel and a link to the OPH Slit Lamp Exam Detail template Parent topic: Physical Exams (Technicians/Assistants)

NextGen® Ophthalmic Suite Help 2022.2

Slit Lamp Exam

The Slit Lamp exam can be documented directly on the Physical Exam panel. A more detailed Slit Lamp exam can be documented on the Ophthalmology Slit Lamp Exam Details template. slit lamp exam panel The following shows the Ophthalmology Slit Lamp Exam Details template. slit lamp exam details window Parent topic: Physical Exams (Technicians/Assistants)

NextGen® Ophthalmic Suite Help 2022.2

Physical Exam Work Summary for Technicians/ Assistants

Mood/Effect – Select the option Normal or Abnormal. Orientation – Select the option Oriented x3 or Abnormal. External Exam Document findings for the External exam on the Physical Exam panel. Enter Pupil Size Dim and Bright findings. To document an External exam in greater detail, click the External Detail link to the left of the exam findings grid to open the External Exam Details template. Slit Lamp Exam Document findings for the Slit Lamp exam on the Physical Exam panel. Enter Angles/pi findings. To document a Slit Lamp exam in greater detail, click the Slit Lamp Detail link to the left of the exam findings grid to open the Slit Lamp Exam Details template. To document Gonioscopy findings, click the Gonio Exam link on the Slit Lamp Exam Details template to open the Gonioscopy – OPH template. (This template can also be opened by selecting the Gonio Detail link to the left of the exam findings grid on the Provider - OPH template. Parent topic: Physical Exams (Technicians/Assistants)

NextGen® Ophthalmic Suite Help 2022.2

Gonioscopy Exam

The detailed Gonioscopy exam is optional. Gonioscopy exam findings can be viewed or documented on the Gonioscopy – OPH template, which can be opened from three different places: Slit Lamp Exam Detail template - during technician/assistant and provider workflow Provider – OPH template – on the Physical Exam panel during provider workflow OPH Physical Eye Exam template – during provider workflow Note: When you make an entry on the Gonioscopy - OPH template causes Gonioscopy to appear in the list of billable procedures on the Finalize - OPH template. You must add a diagnosis code to the Gonioscopy procedure on the Finalize - OPH template. Parent topic: Physical Exams (Technicians/Assistants)

NextGen® Ophthalmic Suite Help 2022.2

Document a Physical Exam (Technicians/Assistants)

The following steps describe the general workflow for documenting findings for Ophthalmology physical exams. While there are differences in the parameters being documented for each exam, the process of entering the data in the exam section on the Physical Exam panel and on the individual exam detail templates is similar for many parameters of most exams. At the top of the panel, indicate the following for the patient: Mood/Affect – Select Normal or Abnormal. Orientation – Select Oriented x3 or Abnormal. Locate the data entry fields for the exam you wish to document on the panel. To document a more detailed exam, click the exam link to the left of the Physical Exam grids to open the corresponding detailed exam template. When the Physical Exam panel is on the Provider - OPH template, an exam link is also found in the exam data entry section on the panel. If the physical exam findings are normal, select the WNL check box for each eye as appropriate, OD and OS. Exam parameter fields corres

NextGen® Ophthalmic Suite Help 2022.2

Physical Exams (Technicians/Assistants)

The exam links listed in the Physical Exam panel depend on whether the panel is on the Prelim Exam - OPH template or the Provider - OPH template. On the Prelim Exam - OPH template (seen as the Prelim Exam tab), the Physical Exam panel includes only exams performed by the technician or assistant, which are later reviewed and updated by the provider. On the Provider - OPH template (seen as the Provider tab), the Physical Exam panel includes additional exams that are only performed by the provider. The Physical Exam panel on the Prelim Exam - OPH template. Documented exam findings appear in separate grids for the right eye OD and the left eye OS. Abnormal findings are indicated with an exclamation mark ! in the grids. The Refresh button causes new or updated exam findings entered on the panel to appear in the grids. Physical exam findings can be documented directly on the panel or you can document a more detailed exam on the corresponding detailed exam template. Detailed exam templates op

External Exam

Recommendations

Physical Exam Elements Documented by Technicians/Assistants

Slit Lamp Exam

Physical Exam Work Summary for Technicians/ Assistants

Gonioscopy Exam

Document a Physical Exam (Technicians/Assistants)

Physical Exams (Technicians/Assistants)

External Exam

Physical Exam Elements Documented by Technicians/Assistants

Slit Lamp Exam

Physical Exam Work Summary for Technicians/ Assistants

Gonioscopy Exam

Document a Physical Exam (Technicians/Assistants)

Physical Exams (Technicians/Assistants)