Physical Exam Work Summary for Technicians/ Assistants

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

Document a Gonioscopy Exam

Note: When you document your exam on the Gonioscopy template, the Gonioscopy code appears in the Procedure Billing grid on the Finalize - OPH template. You must add a diagnosis code to the procedure code prior to submitting the code to the Superbill. Click the Gonio Exam link to open the Gonioscopy - OPH template. gonioscopy - oph template To use copied-forward exam findings from the last documented exam, select the Copy last exam check boxes for OD and OS. Note: You must have privileges to use copy-forward. Each practice can configure provider privileges for exam copy-forward on the Eye Configuration practice template. For more information, go to NextGen Healthcare Success Community and download the latest Setup Guide for NextGen® Ophthalmic Suite. For each eye, document up to four findings, each with one modifier. For each eye, document values for Sup (Superior), Temp (Temporal), Nas (Nasal), and Inf (Inferior) by clicking the fields and selecting one or more values from lists, then

NextGen® Ophthalmic Suite Help 2022.2

Document an External Exam

On the LV Exam - OPT template, expand the Physical Exam panel. To copy the last documented external exam findings to the current exam fields, select the Copy last exam check box. Note: You must have access to use copy-forward. If all external exam findings are normal, select the appropriate External WNL check box for each eye. Exam parameter fields fill with normal default finding values. Enter the pupil size for Dim and Bright light for each eye. Document OD and OS findings as follows: Click Findings field, and select a value from the list. Abnormal findings appear in red font. Click the Modifier field, and select a value from the list. If OD and OS findings for a parameter are the same for both the eyes, click the arrows between the OD and OS fields to copy an entry from one eye to the other. Repeat the steps above for each exam parameter you want to document. To save the documented values as the default values, click the Quick Save, and enter a name for the template. This feature en

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

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

Physical Exam Work Summary for Technicians/ Assistants

Recommendations

Physical Exam Elements Documented by Technicians/Assistants

Document a Gonioscopy Exam

Document an External Exam

Document a Slit Lamp Exam

Gonioscopy Exam

Document a Physical Exam (Technicians/Assistants)

Physical Exam Elements Documented by Technicians/Assistants

Document a Gonioscopy Exam

Document an External Exam

Document a Slit Lamp Exam

Gonioscopy Exam

Document a Physical Exam (Technicians/Assistants)