Physical Exams in Ophthalmology

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

Copy Ophthalmic Exam Findings from Past Encounters

Before you begin You must assign exam copy-forward functionality privileges to individual providers on the Eye Configuration practice template. For more information about configuring copy-forward for exams, go to NextGen Healthcare Success Community and download the latest Setup Guide for NextGen® Ophthalmic Suite. You can copy-forward physical exam findings documented during a past encounter on the Provider – OPH template. You can use the copied exam data as a starting point for the current encounter and make updates to reflect today's exam. Select the Provider tab to open the Provider – OPH template, then expand the Physical Exam panel. Click the Copy Past Exam link below the physical exam grids.The Copy Past Exam – OPH template displays All Providers and the Last 5 Exams. copy past exam - oph template To filter the exams by current provider, select Current Provider in the Show section. To see all of the patient's exams, for Exams, select All Exams. Select the row you want to view or

NextGen® Ophthalmic Suite Help 2022.2

Ophthalmology Provider Workflow

Provider workflow may begin at the Home Page - OPH template, where you can review patient information. The provider workflow for documenting a patient exam continues on the Provider - OPH template. Providers can review tests performed by the technician, document the physical exam, and record tests performed during the provider's portion of the encounter. Complete the Ophthalmology Provider Workflow Provider Summary for Ophthalmic Providers Eye Summary Template Historical Diagnostic Tests View historical orders for diagnostic tests on the Historical Diagnostic Tests - OPH template. General Panel for Providers Document Vital Signs Ophthalmic practices document vital signs on the Vital Signs Lite template. Ophthalmic Orders Provider Medication Review and Update Document and Sign-off HPI as an Ophthalmic Provider Reviewing and Updating the Visual Acuity Exam Findings Update Lensometry and Refraction Findings Review and Update Patient Dilation How to review and update previously documented

NextGen® Ophthalmic Suite Help 2022.2

Slit Lamp and Gonioscopy Exams

A Slit Lamp exam can be documented directly on the Physical Exam panel. A more detailed Slit Lamp exam can be documented on the Slit Lamp Exam Details - OPH template. Links to the Slit Lamp Exam Detail template appear in the External exam section of the Physical Exam panel and in the pane next to the physical exam grids. slit lamp exam details - oph template For providers, a link to the Gonioscopy – OPH exam template is also available. The detailed Gonioscopy exam is optional. Gonioscopy exam findings can be viewed or documented on the Gonioscopy – OPH template. Note: When you enter data on the Gonioscopy template, the system sends the Gonioscopy billing code to the Finalize - OPH tab where you can add a diagnosis code before submitting the code to the Superbill. Document a Gonioscopy Exam Ophthalmic providers can document the Gonioscopy exam on the Gonioscopy - OPH template. Document a Slit Lamp Exam Document a Posterior Exam Detailed Posterior Exam for Macula and Vessels Ophthalmolog

NextGen® Ophthalmic Suite Help 2022.2

Copy Forward Functionality for Ophthalmic Exams

Providers can copy forward exam findings from previous encounters to the exam fields in the current encounter. There are three copy forward options: Copy Past Exam link - opens the Copy Past Exam - OPH template and displays previous exams; gives you the option to filter the exam findings by eye and select the findings you want to copy Copy last exam check boxes - copies the exam from the last visit; located above the corresponding exam fields Copy Last External/Slit Lamp and Copy Last External/Slit Lamp/Posterior - copies the last corresponding exam After you have copied-forward values from a previous encounter, you can update the exam findings to reflect today's exam. Note: Privileges for the copy-forward functionality are configured by the practice for individual providers on the Eye Configuration practice template. For more information about configuring copy-forward for exams, go to NextGen Healthcare Success Community and download the latest Setup Guide for NextGen® Ophthalmic Suit

NextGen® Ophthalmic Suite Help 2022.2

Document an Ophthalmic Physical Exam

The following steps describe the general workflow for documenting findings for the ophthalmic physical exams. While there are differences in the parameters being documented for each exam, the process of entering the data into the exam section on the Physical Exam panel or on the individual exam detail templates is similar for many parameters of most exams. Findings documented by the technician appear in the exam fields and the grids. In the Physical Exam panel, select a value for Mood/Affect and Orientation. Do one of the following: Document the exams in the data fields in the panel. Click the exam link in the left pane of the OD and OS grids to open a detailed exam template. If all findings for a physical exam are normal, select the WNL check box. Exam parameter fields corresponding to the selected check box automatically fill with the normal default values. Note: Findings considered normal defaults are configured on the Eye Configuration practice template. The Eye Configuration pract

Physical Exams in Ophthalmology

Recommendations

Complete the Ophthalmology Provider Workflow

Copy Ophthalmic Exam Findings from Past Encounters

Ophthalmology Provider Workflow

Slit Lamp and Gonioscopy Exams

Copy Forward Functionality for Ophthalmic Exams

Document an Ophthalmic Physical Exam

Complete the Ophthalmology Provider Workflow

Copy Ophthalmic Exam Findings from Past Encounters

Ophthalmology Provider Workflow

Slit Lamp and Gonioscopy Exams

Copy Forward Functionality for Ophthalmic Exams

Document an Ophthalmic Physical Exam