Information Documented on the Postoperative Exam Template

Panel/Section	Description
General Information section	Review or document general information about the surgery, such as procedure and location, status post-procedure, days post-op, and surgeon
Reason for Visit (with History of Present Illness) panel	Review or document a reason for visit and HPI information for the encounter
Visual Acuity exam panel	Review or document visual acuity exam findings
IOP exam panel	Review or document visual acuity exam findings
Examination section	Review or document exam findings for External, Slit Lamp, and Posterior exams. Document intraocular lenses (IOL) that were implanted during cataract surgery
Patient Instructions/Advice section	Select advice and instructions for the patient
Medications section	Patient medications can be reviewed, reconciled, and documented.
Internal Physician Notes section	Providers use this section to keep historical notes that do not appear in generated documents
Impression and Plan section	Providers can document an Impression and Plan for each procedure

NextGen® Ophthalmic Suite Help 2022.2

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. 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 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 lens

NextGen® Ophthalmic Suite Help 2022.2

Postop Exam Template

You can document the following on the Postoperative Exam – OPH template is used for documenting a postoperative exam on one eye after up to two different procedures performed at the same time or a postoperative exam for up to two eyes, so that if the second eye is done within the postoperative period of the first procedure, you have can document for both procedures. The Postoperative Exam – OPH template includes elements such as reason for visit/HPI and exams relevant to following a patient postoperatively so that users can document their activities for the visit on one template. postoperative exam - oph template Information Documented on the Postoperative Exam Template Access the Ophthalmology Postoperative Exam Template How to access the Postoperative Exam - OPH template. Document an Ophthalmic Postoperative Exam Parent topic: Workflows on Visit Focused Templates

NextGen® Ophthalmic Suite Help 2022.2

Complete the Ophthalmology Provider Workflow

For most office visit encounters in general Ophthalmology, the following is a basic outline of the workflow for the provider portion of the visit. To review historical information of the patient, go to the Home Page – OPH template. Go to the Provider – OPH template to document the provider's portion of the encounter. Note: For certain encounters, there are specific single-page visit templates, such as Postoperative Exam – OPH. Select the Provider Summary link to review patient information for today's encounter. Select the Eye Summary link to view current and historical patient findings in a grid. Expand the General panel to review general patient information, the Health Monitor, and Internal Physician Notes. Expand the Orders panel to review, update, and add orders. Expand the Medications panel to review or update medications and perform medication reconciliation, if appropriate. Expand the Reason for Visit panel to review the technician conversation, makes any updates, and sign-off on

NextGen® Ophthalmic Suite Help 2022.2

Begin a New Ophthalmic Encounter

When a patient arrives, intake staff can open the patient chart and the Home Page - OPH template to begin documenting the new encounter for Ophthalmology and Optometry. You can review historical patient data and update allergies and medications. Open the Home Page - OPHtemplate. The template opens with the specialty and visit type defaulted to Ophthalmology and Office Visit. To change the specialty, click the Specialty field, and select a value from the list. To change the visit type, click the Visit Type field, and select a value from the list. Review the information in the following panels: General- review or update the general patient information Health Monitor- review or update the dates of the most recent testing and procedures Historic HPI Impression/Plan Summary- view the history of the patient's impression or plan information Visual Acuity- view the pateint's visual acuity measurements from previous encounters Orders- view and manage orders IOP- view the pateint's intraocular p

NextGen® Ophthalmic Suite Help 2022.2

Information on the Provider Summary - OPH Template

You can open the Provider Summary - OPH template from the Provider Summary link on the Provider tab. The Provider Summary - OPH template provides a complete overview of the patient's clinical information. Information that can be reviewed on the Provider Summary template includes: Panel Information Assessment History Internal Physician Notes Today’s Concerns/Reason for Visit Historic HPI Plan Summary Exam History Vision grids Potential Acuity Meter/Retinal Acuity Meter Cell Count grid Contrast/Glare IOP grid IOP measurements Pachymetry grids Best Corrected Vision and Refraction grids Histories Appointment Requests/Orders Diagnostic Office Procedures All Diagnostic Studies - (outside of the practice) - Labs Procedure History Post Op Exams Ocular History Ocular Medications Systemic Medications Past Systemic History Parent topic: Provider Summary for Ophthalmic Providers

NextGen® Ophthalmic Suite Help 2022.2

Optometry Template Set

The following lists the main templates used in the Optometry template set for Office Visit and Low Vision Exam visits. Template Name Used By Description Home Page - OPH Office Staff, Technician, and Provider Review and update previously documented patient information. You can make updates to general patient information and to the testing dates on the Health Monitor panel Intake – OPT Technician Document patient intake information Provider – OPT Provider Review and update patient information, preliminary exam findings, and document physical exams Skills/Motility - OPT Technician or Provider Document visual skills and motility testing Assessment/Plan – OPH Provider Document assessment, impression, and plan for the patient Finalize - OPH Provider Link procedures to diagnoses, review and update coding, and submit charges to billing Checkout Office Staff Complete the encounter by reviewing the patient plan and checking out the patient LV History Technician Record and review the patient's lo

Information Documented on the Postoperative Exam Template

Recommendations

Document an Ophthalmic Postoperative Exam

Postop Exam Template

Complete the Ophthalmology Provider Workflow

Begin a New Ophthalmic Encounter

Information on the Provider Summary - OPH Template

Optometry Template Set

Information Documented on the Postoperative Exam Template

Document an Ophthalmic Postoperative Exam

Postop Exam Template

Complete the Ophthalmology Provider Workflow

Begin a New Ophthalmic Encounter

Information on the Provider Summary - OPH Template

Optometry Template Set