Physical Exam Elements Documented by Technicians/Assistants

NextGen® Ophthalmic Suite Help 2022.2

External Exam

You can document an external exam directly in the Physical Exam panel. A more detailed External exam can be documented on the External Exam Detail template, opened by clicking the External Detail link to the left of the findings grids in the panel. Note: Some external physical exam elements are only found on the External Exam Detail template. external exam panel The following shows the External Exam Detail template. oph external exam detail window 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 Slit Lamp Exam

You can document a slit lamp exam in the following areas: In the Physical Exam panel, go to the Slit Lamp section. slit lamp exam panel For a more detailed exam, click the Slit Lamp link. Previosuly documented findings appear in the current enocunter fields. To copy the last exam, select the Copy last exam check box. To indicate that the exam findings are within normal limits, select the Slit Lamp WNL check box. Update the exam findings in the corresponding fields. To save the documented values as the default values, click the Quick Save, and enter a name for the template. This feature enables you to use the same values while documenting the same template during future encounters. To load the previously documented default values into the current template, click the Quick Load . For more information on the Quick Load and Quick Save functionalities, go to NextGen Healthcare Success Community, and download the latest Getting Started User Guide for NextGen® Adaptive Content Engine. Note: T

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

Physical Exam Elements Documented by Technicians/Assistants

Recommendations

External Exam

Slit Lamp Exam

Physical Exam Work Summary for Technicians/ Assistants

Gonioscopy Exam

Document a Slit Lamp Exam

Document a Physical Exam (Technicians/Assistants)