nextgen kbm ophthalmology retina user guide version 8.3

Ophthalmology for Retina in NextGen®

KBM version 8.3 User Guide

1.0 NextGen Healthcare Information Systems, LLC

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App Version

Build Number

Date Document Version

Summary of Changes

8.3 NA 11/9/2013 2.0 General Release

8.3 NA 10/23/2013 1.2 Added CMS-CQM and ICD-10 sections; added not about 1-Click assessments

8.3 NA 10/21/2013 1.1 SME reviews and put into AIT.

8.3 NA 6/1/2013 1.0 Initial Release of Document

Revision History

Ophthalmology for Retina in NextGen® KBM version 8.3 User Guide 1.0

11/09/2013 Confidential – Proprietary Information – For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. of 265

Contents

Revision History 4

Chapter 1 Introduction 9 About This Guide ........................................................................................................................ 9 Assumptions .............................................................................................................................. 10 Requirements ............................................................................................................................. 10

Chapter 2 Getting Started with the NextGen Ambulatory EHR 11 Log In, Open a Patient Chart and Create a New Encounter ...................................................... 11 Default and Preferred Templates ............................................................................................... 17

Configuring Default Templates ............................................................................................. 18 Configuring Preferred Templates .......................................................................................... 19

Chapter 3 Getting Started with Ophthalmology in NextGen KBM 23 Ophthalmology Configuration on the Ngkbm_Eyeconfig Practice Template .......................... 23

The Provider Specialty Grid .................................................................................................. 27 Copy Last Exam .................................................................................................................... 29 Sig Filter for Eyeprescriptions (Ophthalmic Medications) ................................................... 29 Print Chart Note .................................................................................................................... 30 IOP Measurements ................................................................................................................ 30 Provider and Technician Signoff ........................................................................................... 31 Use Additional Visual Acuity Fields .................................................................................... 33 Make VA Extended (Visual Acuity) and IOP Extended Read Only .................................... 35 Use Military Time Format for Ophthalmology ASC Time Fields ........................................ 36 Health Monitor Intervals ....................................................................................................... 37 Exam Normal Findings ......................................................................................................... 38

Using the Exam Normal Findings Grid ........................................................................... 39 Joint Commission Standards Standards Configuration and Ophthalmology ............................ 41 Clinical Quality Measures (CQM) for Ophthalmology in NextGen KBM ............................... 43

Quality Buttons and CQM Information Pop-Up Templates for Ophthalmology.................. 43 Ophthalmology - Better Visual Acuity within 90 Days of Cataract Surgery (CMS 133) .... 44 Ophthalmology - Diabetes Eye Exam and Communication with Physician for Diabetes Care (CMS 131 and CMS 142) ...................................................................................................... 44 CMS 143 (NQF 0086) - How to Document Optic Nerve Evaluation for POAG Patients .... 45

Ophthalmology Enhancements to Meet ICD-10 Standards ...................................................... 46 Procedural Billing Grid Redesign ......................................................................................... 46 Today's Assessment .............................................................................................................. 46 Impression and Plan Data ...................................................................................................... 48 Qualifiers for Clinical Content .............................................................................................. 49 Diagnosis Groups .................................................................................................................. 50 Status Fields Added ............................................................................................................... 51

Contents

of 265 Confidential – Proprietary Information – For Use By Authorized NextGen Healthcare Clients Only. Do Not Distribute. 11/09/2013

Clinical Problems Related to Ophthalmology ....................................................................... 51 Diagnosis Categories ............................................................................................................. 52

The Ophthalmology Home Templates ...................................................................................... 52 Launching the Ophthalmology Home Template ................................................................... 52 Ophthalmology Home Templates and Tabbed Template Sets in NextGen KBM Version 8.3 ............................................................................................................................................... 54

Ophthalmology ASC Home Template ............................................................................. 54 The Ophthalmology Home Template for General and Retina ......................................... 55

Chapter 4 Retina Ophthalmology Workflow Basics 61 Configuration Prerequisites for Retina Workflow .................................................................... 61 Retina Ophthalmology Workflow Starting Point ...................................................................... 63

Chapter 5 Retina Ophthalmology Office Visit Workflow 67 Retina Ophthalmology Basic Workflow Outline ...................................................................... 67 Patient Information Bar ............................................................................................................. 68

Key Details about the Patient Information Bar ..................................................................... 68 Information and Links Found on the Patient Information Bar .............................................. 68 Demographic and Medical Information ................................................................................ 69 Alerts ..................................................................................................................................... 70 Links to Other Templates ...................................................................................................... 72 Navigation Buttons ................................................................................................................ 77

Chapter 6 Technician Workflow 81 Ophthalmology Home ............................................................................................................... 81

Review Patient Information on the Home Template ............................................................. 81 Enter or Update Information on the Home - OPH Template ................................................ 82

First Seen .......................................................................................................................... 83 Correction ......................................................................................................................... 83 Advanced Directives ........................................................................................................ 84 Ophthalmology Patient Providers .................................................................................... 86 Health Monitor ................................................................................................................. 88 Vision (Visual Acuity) ..................................................................................................... 89 IOP (Intraocular Pressure) ............................................................................................... 91 Allergies (Brief) ............................................................................................................... 92 Ocular Medications .......................................................................................................... 93 Ocular History .................................................................................................................. 94

Tech Signoff - Home ............................................................................................................. 94 Navigate to the CC-HPI-ROS Tab ........................................................................................ 95

Ophthalmology CC-HPI-ROS................................................................................................... 95 General Patient Information .................................................................................................. 96 Health Monitor (Summary) ................................................................................................... 97 Retina History of Present Illness (HPI) ................................................................................. 98 Review of Systems (ROS) ................................................................................................... 101 Generate Progress Note ....................................................................................................... 105 Tech Signoff - CC-HPI-ROS .............................................................................................. 106

Retina Ophthalmology History ............................................................................................... 107



Medications ......................................................................................................................... 109 Documenting Medications in the Medications Module ................................................. 113 Medication Reconciliation for a Patient ......................................................................... 116

Allergies .............................................................................................................................. 120 Ocular History ..................................................................................................................... 123

Documenting Ocular History ......................................................................................... 124 Documenting Ocular Procedures ................................................................................... 125

Systemic History ................................................................................................................. 126 Past Medical and Surgical History ................................................................................. 127 Interim History ............................................................................................................... 134

Family History ..................................................................................................................... 135 Documenting Family Health History ............................................................................. 136

Social History ...................................................................................................................... 142 Blood Sugar ......................................................................................................................... 147 Generate Note - History Summary ...................................................................................... 148 Tech Signoff - History ......................................................................................................... 149

Ophthalmology Pre-Screening ................................................................................................ 149 Ophthalmology Tech Exam .................................................................................................... 151

Visual Acuity Exam ............................................................................................................ 153 Lensometry and Refraction ................................................................................................. 154

Documenting Lensometry Findings ............................................................................... 155 Documenting Autorefraction Findings .......................................................................... 156 Documenting Manifest Refraction and Visual Acuity Findings .................................... 157 Documenting Cycloplegic Rx and Dva Findings .......................................................... 158

Keratometry Exam .............................................................................................................. 160 Amsler Grid ......................................................................................................................... 161 IOP Exam ............................................................................................................................ 162 External Exam ..................................................................................................................... 163 Drawings ............................................................................................................................. 166 Generate Tech Report .......................................................................................................... 167 Tech Signoff - Tech Exam .................................................................................................. 167

Chapter 7 Provider Workflow 169 Provider Start ........................................................................................................................... 169

Provider Signoff - Exam ..................................................................................................... 171 Retina Ophthalmology Exam .................................................................................................. 172

External Exam ..................................................................................................................... 172 Slit Lamp Exam ................................................................................................................... 174

Gonioscopy Exam .......................................................................................................... 176 Posterior Exam .................................................................................................................... 177

AMD Detail Exam ......................................................................................................... 184 Vitreomacular Detail Exam ........................................................................................... 186 Histo (Presumed Ocular Histoplasmosis) Detail Exam ................................................. 187 BDR (Background (Non-Proliferative) Diabetic Retinopathy) Exam ........................... 188 PDR (Proliferative Diabetic Retinopathy) Exam ........................................................... 190 Vascular Detail Exam .................................................................................................... 191

Contents


Ophthalmology Drawing Module ....................................................................................... 193 Procedures (Brief) ................................................................................................................... 195 Impression and Plan ................................................................................................................ 196

Surgery Scheduling ............................................................................................................. 196 Scheduling a Surgery in Ophthalmology ....................................................................... 198

Provider Communications ................................................................................................... 203 Assessment/Plan .................................................................................................................. 203

Select Today's Assessments ........................................................................................... 205 Document Impression .................................................................................................... 213 Document a Plan ............................................................................................................ 214 Coding ............................................................................................................................ 225 Generate Chart Note ....................................................................................................... 235

Chapter 8 Procedures - Workflow Shared Between Providers and Technicians 237 Procedures Template ............................................................................................................... 237 Retinal Testing and Procedures Workflows ............................................................................ 238

Scheduling and Tasking Retinal Tests and Office Procedures ........................................... 239 Consent Forms ..................................................................................................................... 242 Patient Dilation and Other Medications (Eye Drops) ......................................................... 245 Retinal Lasers ...................................................................................................................... 247 Retinal Procedures (Other) .................................................................................................. 250 Retinal Diagnostics ............................................................................................................. 254

Request Diagnostic Tests ............................................................................................... 255 Perform Diagnostic Tests ............................................................................................... 256 Interpretation of Diagnostic Test Results ....................................................................... 257 Diagnostic Test Reports ................................................................................................. 259 Retina Diagnostic Tests on the Testing Tab .................................................................. 259

Index 263



In NextGen KBM version 8.3, the Ophthalmology templates for the Retina Ophthalmology sub-specialty Office Visit used by retina ophthalmology specialists continue to use the same 10-tab workflow used previous versions of NextGen KBM®.

NextGen KBM version 8.3 is a first step in transitioning the Ophthalmology specialty into the Framework template set, beginning with General Ophthalmology. The goal is to provide users with a greatly improved overall experience using the latest enhancements. These enhancements combine to improve navigation and and ease of use, along with a more standardized workflow that also includes the ability to to configure elements easily in order to create a preferred workflow. In a future release, the Retina sub-specialty will be incorporated into the new workflow.

This document serves to provide users with a basic understanding of the Ophthalmology Office Visit templates for the Retina sub-specialty currently used with NextGen KBM version 8.3. This document assumes that you already know how to start the NextGen Ambulatory EHR application, how to log into the system, how to open a patient chart, and basic navigation.

The NextGen® KBM version 8.3 Retina Ophthalmology User Guide explains the templates and how to use them, along with the workflow for documenting a retina ophthalmology office visit encounter.

About This Guide This guide serves to provide readers with a basic understanding of the Ophthalmology Office Visit templates for the Retina sub-specialty in NextGen® KBM version 8.3 and how to use them. This document assumes that you already know how to start the NextGen Ambulatory EHR application, how to log into the system, how to open a patient chart and basic navigation.

The intended audience for this guide is any user who will be using the Retina Ophthalmology sub-specialty workflow of the Ophthalmology specialty templates in NextGen KBM version 8.3 to document an office visit encounter or patient information.

Note: In NextGen KBM version 8.3, General Ophthalmology users can choose to use the new workflow being introduced in NextGen KBM version 8.3 or to continue to use the NextGen KBM version 8.1 workflow. If General Ophthalmology users choose to continue to use the NextGen KBM 8.1 workflow, they should select to use the Home – Oph (eyemaster_im) template as their starting point. For the Ambulatory Surgical Center (ASC) and Retina Ophthalmology sub-specialties, the workflow remains the same as it was in NextGen KBM version 8.1, and continues to use the Home – Oph (eyemaster_im) and ASC Home – Oph (eyeasc_home) templates as their respective starting points.

C H A P T E R 1

Introduction

Chapter 1 Introduction


Assumptions This guide assumes that you have the following basic and advanced computer skills:

Microsoft® Windows® operating systems

Microsoft® Office applications

NextGen® Ambulatory EHR

Requirements This user guide does not require the reader to have access to the NextGen Ambulatory EHR with the NextGen KBM Ophthalmology templates installed, or to be logged in to the system.



To get started, you must have a valid user ID and password to log into the system. After logging into the system, open a patient chart and create a new encounter. Once you have logged into the system, you can also configure what templates to open by default, whether to start your workflow from the Inbox module, and and other details for working with the NextGen Ambulatory EHR and the templates shipped with the system, including configuration details specific for your specialty.

In this chapter, we will briefly cover the basics of logging into the NextGen Ambulatory EHR, opening a patient chart, creating a new encounter and configuring default and preferred templates.

Log In, Open a Patient Chart and Create a New Encounter 1 Start the NextGen Ambulatory EHR using the NextGen Application Launcher and log into the

system. Click EHR on the Application Launcher to launch the NextGen Ambulatory EHR application

and password window. If different from what is displayed, select your enterprise and practice. Enter your user name and password, and then click Logon.

C H A P T E R 2

Getting Started with the NextGen Ambulatory EHR

Chapter 2 Getting Started with the NextGen Ambulatory EHR


The following screen capture shows the NextGen Application Launcher and the link to the NextGen Ambulatory EHR. Depending on your system setup, you may see more or fewer shortcuts for applications than shown.

The screen capture that follows shows the Login dialog box in NextGen Ambulatory EHR version 5.8. Beginning with this version, a PIN pad will no longer be a supported method for logging into the system due to HIPAA regulations.

2 Open a patient chart. At the main screen of the application, click the Patient toolbar button to open the Patient

Lookup dialog box. Search for your patient by typing a few letters of their last name or date of birth, and click

Search to refresh the list.



Double-click the patient in the list to open the electronic chart. The following screen capture shows the Patient Lookup dialog box launched by clicking the Patient toolbar button.



The following shows a view of a patient chart that has been opened. In this case, no templates have been configured to open automatically, nor has the Inbox been configured as the workflow starting point.

Note: If you have not configured a preferred template to open, the patient chart will open to a blank screen. If you are configured to start with the Inbox, the Inbox will open when you first log on, before a patient's chart is opened. The medical records template default is what will open when you open a patient's chart.

3 Create a new encounter

Caution: If the practice is using NextGen® Practice Management, the encounter should be opened automatically, and this step can be omitted. Creating an encounter in this case would result in a clinical encounter that is separate from the billable encounter.

Click the New toolbar button in the History toolbar.

- or-

Use the Custom Encounter feature to create an encounter that has happened in the past Click the File menu > New > Custom Encounter submenu Select the date and time from the Calendar dialog box and click on OK.

Note: Custom Encounter is never used to for today's encounter.



Shown below, clicking the New button on the Patient History toolbar to create a new encounter. The new encounter will be created with the current system date and time.



Shown below, creating a new Custom Encounter.

The Custom Encounter calendar dialog box is used to select a date and time for an encounter that occurred in the past.



Default and Preferred Templates If you are going to be working with the same specialty each time you log into the system, you can configure your system to open that specialty's Home Page template automatically whenever you open a patient chart and create a new encounter by configuring it to be a default medical records template. You can also create a list of “preferred” templates that you often use so that you no longer have to search through the entire list of all templates available in the system when you want to open one of them using Template Launcher. A Preferred Templates list is particularly helpful to those users who may work with more than one specialty. Both features help users quickly navigate to their preferred starting point within the system.

Default templates and a Preferred Templates list are setup in user Preferences. Here, you can set a template to open by default when you open a patient and create a new encounter by selecting a preferred medical records template and/or a preferred demographics template. You can also create a Preferred Templates list.

In the following examples, we will use the General Ophthalmology specialty to show how to configure a default template and how to create a personal list of preferred templates.

Navigate to Preferences

Click the Tools menu > Preferences submenu > Templates tab

The following screen capture shows the Preferences property tabs. This is where individual users can set their own preferences for the application. This area is also referred to as "User Preferences". In this example, the user is setup to automatically start their workflow from the Inbox when they log into the system.



Configuring Default Templates In the following example, oph_home_page (the General Ophthalmology Home Page template) has been selected as the default medical records template.

Note that when you select both a default medical records template and a default demographics template, the patient chart will open to display the demographics template.

Configuring a Default Medical Records Template:

1 Open Preferences to the Templates tab. Click the Tools menu > Preferences submenu > Templates tab.

2 Select Template Type: Medical Records

3 Select Default Template. In this example, select: oph_home_page (This is the formal name of the 'Home Page -

OPH' template.) a) Click the down-arrow.

b) Scroll down through the list of template names.

c) Click the template you want.

4 Click Apply.

Note: The Default Template drop-down list in Preferences will display the formal names of templates used in Template Editor. This name is different from the display name seen in run-time, which is the more user-friendly name. Display names are seen in the Templates Available list seen in the section found above the default template fields. You can use Template Editor to cross-reference the display name of a template to its formal name by selecting to search for a template using its display name.

The following screen capture shows the Preferences tabs opened to the Templates tab, and setting the default medical records template.



Selecting the "Open from Work Flow Appts" check box will open this template by default from the Inbox Appointments section.

Summary of Steps to Configure a Default Template

1 Select the template Type.

2 Select the Default template to open.

3 Click Apply.

4 Click OK to close the Preferences tabs. Templates listed in the Available Templates list box are listed using their display name.

In the drop-down list used to select a preferred template to open, templates are listed by their formal Template Editor name.

Configuring Preferred Templates A Preferred Templates list is a list of templates that a user prefers to use and wants to access quickly and easily. When a list of preferred templates has been created, those templates will appear listed in the Template Launcher Select Template dialog box when the Show “Preferred” radio button is selected. Show “Preferred” is selected by default when you first open Template Launcher.



The following shows the Template Launcher Select Template dialog box with the option to show "Preferred" templates before any templates have been configured as Preferred in Preferences.

Preferred templates are configured in upper section of the Templates tab in Preferences using the Available Templates list, the Preferred Templates list, and the selection arrows found between them.

Adding a Template to the Preferred Templates List

1 Scroll down the Available Templates list on the left side to locate the template you want to select.

2 Click on the template name in the list to highlight it.

3 Click the Right Arrow button to add the highlighted template to the Preferred Templates list on the right side.

4 The template will be displayed in the Preferred Templates list on the right. (It will still appear in the list of Available Templates on the left.)

5 After selecting the templates you want to add to the list, click Apply.

6 If you have finished configuring your preferences, click OK to close the Preferences tabs.

Note: Clicking the double Right Arrow button will copy the entire list of available templates in the Available Templates list to the Preferred Templates list on the right.



The following screen capture shows selecting the *Intake template in the Available Templates list and adding it to the Preferred Templates list.

Removing a Template from the Preferred Templates List

1 Scroll down the Preferred Templates list on the right side to locate the template you want to select.

2 Click on the template name in the list to highlight it.

3 Click the Left Arrow button to remove the highlighted template from the Preferred Templates list on the right side.

4 After selecting the templates you want to remove from the Preferred Templates list, click Apply.

5 If you have finished configuring your preferences, click OK to close the Preferences tabs.

Note: To remove all templates listed from the Preferred Templates list on the right, click on the double Left Arrow button. The Preferred Templates list will be cleared.



The following screen capture shows the Preferred Templates list after several templates have been selected.

The Template Launcher Select Templates dialog box showing the templates in the Preferred Templates list when the Show "Preferred" radio button is selected.



The NextGen® KBM Ophthalmology templates include workflow for three areas of Ophthalmology workflow: General, Retina, and Ambulatory Surgical Center (ASC). Before you can use the Ophthalmology templates in NextGen® KBM, setup and configuration must be performed.

For General Ophthalmology using the new template set introduced with NextGen KBM version 8.3, content should be reviewed on the ngkbm_foundation_content system template.

Template configuration settings specific to General Ophthalmology, Retina, and Ophthalmology ASC's continue to be made using the ngkbm_eyeconfig practice template, and NextGen KBM practice level configurations are made using the ngkbm_config practice template.

In this section, we will cover content setup and configuration settings for the Ophthalmology specialty using the system and practice templates.

In order to review these configuration settings, you must have a valid user ID and password to log into the system. You must also have security rights to access and make changes using system and practice templates.

Note: The intended audience for this chapter is system administrators, office managers, or anyone who will be responsible for setting up and/or maintaining the system at the practice.

Ophthalmology Configuration on the Ngkbm_Eyeconfig Practice Template The Ngkbm_Eyeconfig system template was originally introduced in NextGen KBM version 7.5. This template is used for configuring different options and functionalities that are specific to the Ophthalmology specialty template set.

Navigate to the Ngkbm_eyeconfig system template:

1 After logging into the system.

2 Open the appropriate system or practice template. Click File menu > System / Practice Template submenu.

3 The Select Template dialog box displays. Select the following to display a list of practice templates: View “All”

C H A P T E R 3

Getting Started with Ophthalmology in NextGen KBM

Chapter 3 Getting Started with Ophthalmology in NextGen KBM


Practice tab 4 Scroll down the list and double-click on “Ngkbm Eyeconfig” to open the template.

Seen below, open a system or practice template by clicking the File menu, System/Practice Template submenu.



The Select Template dialog box is seen below. Select the option to show "All" and then select the Practice tab. Scroll down through the list of practice templates to locate the template you want. Double-click on the template name displayed in the list to open it.



The ngkbm_eyeconfig practice template, page 1.



The ngkbm_eye config practice template, page 2.

The Provider Specialty Grid The Provider Specialty grid can be used by the Ophthalmology specialty to assign providers to different sub-specialties of Ophthalmology. This can be completed for Ophthalmology providers so that when they launch their specialty templates, Ophthalmology template navigation will be configured for their sub-specialty. Currently, existing Ophthalmology sub-specialties include General (includes ASC) and Retina.

To assign a provider to an Ophthalmology sub-specialty, right-click in the grid and select “Add new” from the drop-down menu to launch the Ophthalmology Provider Specialty practice pop-up template (ngkbm_eyeprovider) to assign a provider to a sub-specialty, if desired, and to select whether to use the option to copy last exam forward. (The default setting is to not use copy last exam forward.) You can update an existing provider record by double-clicking on a row in the grid.

The Provider Specialty grid can be used by the Ophthalmology specialty to assign providers to General Ophthalmology or Retina. This is an optional setting for generalists. If a provider is only seeing Retina patients, then assigning the provider to the "Retina" specialty will save time in their workflow. This setting is also used to give privileges to individual providers to be able to copy forward portions of their last exams to a new encounter.



To assign a new provider to an Ophthalmology sub-specialty:

1 Right-click on the grid and select “Add new” from the drop-down menu to open the “ngkbm_eyeprovider [New Record]” template.

2 Click in the Provider Name field to launch the Provider Mstr dbpicklist.

3 Locate the provider name in the list and double-click on it to select.

4 Click in the Specialty field and select the specialty from the picklist. (This is optional and should only be considered if a provider only does Retina.)

5 Select the “use copy last exam forward” check box in order to select that the provider be permitted to use the Copy Forward Last Exam function. (This setting is optional and will be discussed in the next section.)

6 Click Save and Close in the bottom toolbar.

The Provider Specialty grid, where you configure what Ophthalmology sub-specialty a provider is assigned to, and whether or not the practice wants to permit that provider to use the Copy Last Exam Forward function.

At the ngkbm_eyeprovider [New Record] template, click in the Provider Name field to launch a dbpicklist with all of the providers in the system for that practice.



Click in the Specialty field to open a picklist of current Ophthalmology sub-specialties. At this time, the General and Retina sub-specialties are available. The specialty may be left blank if the provider is a generalist.

Copy Last Exam The Copy Last Exam setting is a check box found on the ngkbm_eyeprovider pop-up template that is launched from the Providers data grid on the ngkbm_eyeconfig practice template. When setting up an Ophthalmology provider for an Ophthalmology sub-specialty, there is a check box for “use copy last exam forward” that can be selected. This configures the system to pull information from the last exam forward to the current exam. In versions 7.9.x and earlier, information for a completed exam from the last encounter would be pulled forward when this setting was selected. With version 8.0.x, this was changed so that information from the last time the exam template(s) were opened will be pulled forward to the new encounter.

Note: Copy Last Exam in NextGen KBM versions 8.x Copy Last Exam pulls forward information from the last time the exam templates were opened. Exam templates include: Brief Examination (eyeBriefExam), External Examination (eyeExternalExam), Slit Lamp Examination (eyeSlitExam).

Sig Filter for Eyeprescriptions (Ophthalmic Medications) In previous versions of the Next Gen KBM, eye prescriptions were ordered from within the Ophthalmology templates. The customizable Sig Filter for "EyePrescriptions" was designed in NextGen KBM version 7.7 to allow typical eye Sigs to be loaded into a list for ease of prescribing ophthalmic medications, drops, or ointments.

At this time, however, all medications are ordered from the Medication Module to facilitate electronic prescribing, and this section is not used.



Note: In NextGen KBM version 8.3, this feature has been retained for historical purposes, but is no longer being used to filter Ophthalmic medications. All medications are now ordered from the Medication Module.

Print Chart Note The Print Chart Note setting is a check box found on the ngkbm_eyeconfig practice template that is used to automate the generation of a Chart Note at the end of every encounter when coding is submitted to billing. Selecting the check box for “Print the chart note when the submit button is clicked on the coding template.” will cause a Chart Note to be generated offline automatically when the “Submit Code” button on the Coding tab template (oph_em_code) is clicked at the end of every encounter. When generating the Chart Note offline, no preview screen will appear.

Note: An offline document generator has to be set up before documents can be generated offline.

IOP Measurements The check box for “Use kPa fields for IOP measurements” can be selected so that additional fields are displayed to enter kilopascal values in the IOP panel or section, which are saved as additional columns in the IOP data grids on the Ophthalmology Tech Exam pop-up template and the Home Page tab template in the new 5-tab workflow, and on the very bottom of the second page of the Tech Exam tab template (eyeTechExam), the Exam tab template (eyeBriefExam) at the very bottom of the first page, and the Provider Start template (retptsummary) in the 10-tab workflow. By default, this setting is not selected.

New with NextGen KBM version 8.3, users now have the ability to define high and low abnormal values for measurements in mm Hg and kPA. The IOP Measurements section showing the check box for "Use kPa fields for IOP measure", along with high and low abnormal measurement values defined.



Click in the field and enter a value using the onscreen numeric keypad.

Provider and Technician Signoff The check box to Hide provider and tech sign-off will cause the Provider and Tech sign-off check boxes found at the top of each of the tabbed templates in the Ophthalmology tabbed Office Visit template set to not be visible when it is selected. By default, this setting is not selected. These check boxes are used by the Tech and the provider to indicate that they have reviewed and completed each template.

Note: These signoff check boxes are seen when using the older 10-tab workflow used in NextGen KBM version 8.1. They are not seen in the new version 8.3 workflow. This signoff feature is not a legal sign-off, but only a visual cue. This is an optional feature.



When the Tech signoff check box is selected before the Provider signoff, a green check mark in a white box will appear on the tab. The name of the logged in user will appear in the sign-off fields along with a current system date and time stamp when the check box was selected.

Whenever the Provider signoff check box is selected, the box on the tab will stop being displayed, even when the Tech signoff is selected after the Provider. The name of the logged in provider will appear in the sign-off fields along with a current system date and time stamp when the check box was selected. (This is different from previous versions, which displayed a green check box with a white check mark.)

Templates that have not been signed-off will display a bright red circle with a white “x” on it, alerting users that sign-off needs to be completed.

The Ophthalmology configuration setting for Provider and Technician check boxes, which appear on every tab of the earlier 10-tab Ophthalmology office visit template set by default (version 8.1 workflow). Clicking this check box will cause those check boxes to not be displayed on tabs. (This feature is no longer used in the new 5-tab Ophthalmology template set being introduced with NextGen KBM version 8.3.)

The Tech and Provider signoff check boxes, seen on the earlier 10-tab Ophthalmology template set. On the Tech Exam tab, the Tech has signed-off on the template. The other templates in the tabbed Office Visit have not been signed-off.

The Provider signoff check box has now been selected, and the signoff icon changes so that it is no longer displayed on the tab. None of the other templates have been signed-off.

Signoff check boxes are no longer found on the top tabs of the new 5-tab Ophthalmology template set in NextGen KBM version 8.3.



Use Additional Visual Acuity Fields The check box to Show additional visual acuity fields will cause the additional fields to be displayed on the Visual Acuity extended pop-up template, which will allow the recording of additional types of visual acuities such as intermediate, cycloplegic, best corrected, and brightness acuity testing acuities. These fields are accessible by double-clicking on the Visual Acuity grid found on the Tech Exam pop-up template to open the Visual Acuity extended pop-up template for adding a new record. Note that these additional Visual Acuity measurement fields do not print on documents.

By default, this setting is not selected. The following screen captures show how the Visual Acuity extended pop-up template appears when this check box has not been selected and when it has.



The Visual Acuity extended pop-up template, as it appears when the check box for using additional visual acuity fields has not been selected.



The Visual Acuity extended pop-up template, as it appears when the check box for using additional visual acuity fields has been selected.

Make VA Extended (Visual Acuity) and IOP Extended Read Only This setting allows practices to decide how many days the data fields on the VA extended pop-up template and the IOP extended pop-up template will be allowed to remain editable, allowing changes to be made to the data. After the number of days shown in the Text field, the data entry fields on both the VA and the IOP extended pop-ups will be disabled from making any changes and will be read-only.

Leaving this field empty means that the time for making changes is unlimited. To set a time limit, click in the field and use the up-arrow to scroll though increasing numbers until you have the desired time limit in number of days. The time limit can be changed at any time. If after setting a time limit, you wish to return to unlimited, simply reset the limit by selecting zero days.



Note: Only the person who entered the Visual Acuity or Intraocular Pressure can edit their own entry.

Use Military Time Format for Ophthalmology ASC Time Fields This setting provides practices with the ability to decide what time format to use for fields related to Time for Ophthalmology ASC, using 24-hour time format or using the 12-hour time format with “AM” and “PM”. This configuration setting is specific to the Ophthalmology ASC templates.

Selecting the “Use Military format” check box will cause the time fields on the Ophthalmology ASC templates to display time values using the 24-hour time format, referred to as “Military time”.

Leaving this check box not selected means that the time fields on the Ophthalmology ASC templates will display time using the 12-hour format with “AM” and “PM. By default, this configuration setting is not selected.

Below shows the "Use military format" check box selected in order to configure the Ophthalmology ASC templates to use military format, the 24-hour time format, when displaying time.

In the following example, the "Use military format" check box has been selected, and the Ophthalmology ASC templates are configured to use military format, the 24-hour time format, when displaying time.



The Ophthalmology ASC OR Record tab template, showing an example of a time field displaying time in standard 12-hour format with AM and PM when the "Use military format" check box is not selected.

Health Monitor Intervals The Health Monitor Intervals section allows practices to decide what the time interval that different exams and tests are performed should be. These time intervals are reflected in the Health Monitor section found on the Home Page – OPH template and on the Intake tab and Provider tab templates. When an exam or test has been performed for a patient, the last date it was completed will be displayed in the date field corresponding to that exam or test. This date will appear in black font until the time interval specified in the Health Monitor section passes, and then the date will appear in red font to alert users that the exam or test is past due.



Exam Normal Findings Caution: The Exam Normal Findings data grid is used for customizing the wording for normal findings for Ophthalmology exam elements, together with additional template and picklist customizations that must be made in Template Editor. Making changes on this data grid alone will not change the values for Ophthalmology exam findings when the normal defaults are selected within the Exam templates.

On Ophthalmology Exam templates, there are defined exam elements for each type of exam. When documenting findings for an exam, clicking in the fields corresponding to an exam element will launch a picklist of findings appropriate for that element. The first item in each picklist is the normal finding for that element. When a user selects the normal finding from the picklist, it will be displayed in the field in black font. When a user selects any of the other findings (which are considered abnormal) from the picklist, they will be displayed in the field in red font. In NextGen KBM version 8.3, abnormal or different findings are also displayed in an Abnormal Exam Values data grid, found above the exam grids. Normal findings are displayed in the Exam grid only.

If a normal default is changed in the ngkbm_eyeconfig practice template, free-typing that finding will cause the finding to display in black font and not appear in the Exam Abnormals section. However, the finding will need to be added to the picklist in Template Editor to find it easily.

The Exam Normal Findings section is found at the bottom of the ngkbm_eyeconfig practice template, and is being introduced with NextGen KBM version 8.3. The Exam Normal Findings section allows clients to customize the wording for normal findings for individual elements of Ophthalmology exams. In the past, findings for normal were hard-coded and were documented by selecting the first item in a findings picklist for an exam element. With this new feature, the system is shipped with normal findings defined and configured for exam elements that are not hard-coded. Clients are able to make changes to how they are worded as needed to meet their own preferences by making changes on the Exam Normal Findings grid and additional edits to picklists and triggers in Template Editor.

Note that changes made to a normal finding on the Exam Normal Findings grid for an exam element will not affect what appears for a normal finding in the corresponding exam picklist. You will also have to edit the exam picklist in Template Editor so that the modified value that appears in the Exam Normal Findings grid also appears in the picklist. There can be more than one normal finding for an exam element set up in the Exam Normal Findings grid (meaning that the findings(s) will not be flagged as abnormal), however only one finding will display when the normal default check box for a selection is checked.



Below is the Exam Normal Findings section found at the bottom of the Ngkbm_Eyeconfig practice template.

Using the Exam Normal Findings Grid An exam element is an individual item that is examined during the encounter, such as pupils, Iris, Anterior Chamber or CVF (Confrontation Visual Fields). Values for normal findings for exam elements can be seen listed in the grid.

To modify the existing Normal findings for an exam element:

1 Double-click on the row in the grid displaying the exam element to open the oph_norm_findings_ex extended pop-up template, or right-click on the row and select “Open” from the drop-down menu.

2 Make any edits to the value displayed in the Normal Finding field.

3 Click the Save toolbar button at the bottom of the template.

4 Alternatively, to add a second "normal" finding for an exam element:

a) Right-click on the grid and select "Add new".

b) Click in the Exam Element field and select the desired exam element from the picklist.

c) Click in the Normal Finding field and type the finding that should also be considered normal using free text.

Note: This must be typed in exactly as it will be used on the exam templates.

d) Click Save.

5 If you have finished, click Close.

Once you have completed making your modifications at the Exam Normal Findings grid, depending on the changes you have made, you are ready to do the next steps in Template Editor.



In Template Editor, you will have to make changes to the following:

The exam picklist(s) so that they display the newly modified normal finding(s) as the first item(s) in the list

The color change triggers that indicate normal/abnormal findings on the pop-up templates

The triggers that set which findings populate when 'Normal Default' is clicked

To add a new normal finding, double-click the row in the grid or right-click on the Exam Normal Findings data grid and select "Open" from the drop-down menu.

Below, we see the oph_norm_findings_extended pop-up template, launched from the Exam Normal Findings data grid.



Click in the Exam Element field to launch a complete picklist of exam elements for Ophthalmology.

Joint Commission Standards Standards Configuration and Ophthalmology The Joint Commission Standards (formerly known as the Joint Commission on Accreditation of Healthcare Organizations or JCAHO) configuration setting for all KBM templates can be found on the Ngkbm_Config practice template. This setting should be selected by those practices that are required to adhere to The Joint Commission Standards. When the check box for Enable The Joint Commission Standards is checked, all additional fields and links related to The Joint Commission related content currently found within the KBM will be enabled. Occasionally, this may affect documentation workflow.

In Ophthalmology, one feature enabled by The Joint Commission can be found on the Ophthalmology procedure templates, where three of the consent check boxes become required. An alert will be displayed, indicating that Consent was obtained, the correct patient identified, and the correct side and site confirmed check boxes must be checked before submitting.

The Ophthalmology procedure templates are:



eyeAnteriorLaser

eyeBotoxInjection

eyeOfficeSx

eyePosteriorLaser

oph_generic_office_procd

retOfficeProcedure

retOfficeproother

retOfficeprocedureinject

Configuring The Joint Commission Standards

1 Launch the Ngkbm_Config pratice template Log into NextGen Ambulatory EHR. Click File menu > System/Practice Templates submenu > Practice tab > select Show “All” >

double-click on “Ngkbm_Config” to open. 2 At the Ngkbm_Config system template, choose your setting

Scroll down the length of the template until you see “The Joint Commission Standards”. Configuration settings are organized in alphabetical order by item or category, with related items categorized together.

Select the “Enable The Joint Commission requirements” check box to enable The Joint Commission standards.

Return to the top of the template. Click Save and Close.



Clinical Quality Measures (CQM) for Ophthalmology in NextGen KBM The Centers for Medicare & Medicaid Services (CMS) Hospital Reporting (HR) 2012 EHR Incentive pilot program requires the reporting of information through the submission of electronic health record data. The required information relate to Clinical Quality Measures (CMS). Quality measures are used determine the standard of care being provided to the patient. In NextGen KBM version 8.3, there are 64 individual measures that providers can choose to track for reporting purposes.

In NextGen KBM version 8.3, clinical quality measures for Ophthalmology include:

Primary Open Angle Glaucoma AKA Optic Nerve Evaluation

Diabetes Eye Exam

Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery A brief description of these measures and workflow scenarios follow.

Reference: For detailed information about CMS clinical quality measures and the CQM Check in NextGen KBM version 8.3, please refer to the NextGen KBM 8.3 CQM Check Whitepaper.

Quality Buttons and CQM Information Pop-Up Templates for Ophthalmology Quality buttons have been added to various Ophthalmology templates and will launch information pop-up templates containing information about the associated clinical quality measure.

The Quality button that opens the CQM - Diabetes Eye Exam information pop-up template appears in the following locations:

The Health Monitor panel on the Intake and Provider templates

The Dilation/Other Medications panel on the Intake and Provider templates

The Dilation/Other Medications - OPH pop-up template

The Quality button that opens the CQM - Posterior Exam Detail information pop-up template appears in the following locations:

The OPH Physical Exam template

The OPH Posterior Exam Detail pop-up template



Ophthalmology - Better Visual Acuity within 90 Days of Cataract Surgery (CMS 133) NextGen KBM 8.3 for Ophthalmology provides the ability to document visual acuity in patients following cataract surgery.

To document visual acuity in patients following cataract surgery:

1 Click the Add button in the Past Ocular History panel to open the Ocular Histories - OPH template.

2 Select the Cataract option.

3 Enter the appropriate information in the pertinent fields about the patient's past history.

4 Click Save. 5 Click Close.

To document the Visual Acuity Panel:

1 Click the Intake tab.

2 Click the Add button in the Visual Acuity panel to open the Oph Eyetech template.

3 Complete any pertinent fields with patient data on the Visual Acuity panel on the Oph Eyetech template.

4 Click Save & Close.

Ophthalmology - Diabetes Eye Exam and Communication with Physician for Diabetes Care (CMS 131 and CMS 142) NextGen KBM 8.3 for Ophthalmology provides the ability to document a retinal or dilated eye exam in patients with diabetes.

To document a retinal or dilated eye exam:

1 Click Physical Eye Exam in the Physical Exam panel on the Provider template.

The OPH Physical Eye Exam template opens.

2 Click the Dilation active text link.

The Dilation/Other Medications - OPH template opens.

3 Enter any relevant information in the Dilated, Eye, Time of dilation, and By fields.

4 Click Save & Close to return to the OPH Physical Eye Exam template.


6 Click Posterior Detail in the Physical Exam panel.

The OPH Posterior Exam Detail template opens.

7 Document findings in either side (OD and OS).




NextGen KBM 8.3 for Ophthalmology provides the ability to document a dilated macular or fundus eye exam in patients with diabetic mellitus.

To document a dilated macular or fundus eye exam:

1 Click Physical Eye Exam in the Physical Exam panel on the Provider template.

The OPH Physical Eye Exam template opens.

2 Click the Dilation active text link in the Posterior section of the Slit Lamp and Posterior panel.

The Dilation/Other Medications - OPH template opens.

3 Enter any relevant information.

4 Click Save & Close to return to the OPH Physical Eye Exam template

5 Enter all relevant information in the Macula section.


To document physician communication:

1 Click Documents in the left navigation bar.

The Document Library - OPH template opens.

2 Select the Include chart note check box.

3 Click the Standard diabetic exam letter active text link to generate the document.

CMS 143 (NQF 0086) - How to Document Optic Nerve Evaluation for POAG Patients NextGen KBM for Ophthalmology provides the ability to document optic nerve head evaluation in patients with Primary Open Angle Glaucoma (POAG).

To document optic nerve evaluation:

1 Click the Provider tab.

2 Click Posterior Detail on the Physical Exam panel.

3 Document any pertinent information in the Optic Nerve section of the OPH Posterior Exam Detail template or select the Posterior WNL check box for either side of the eye (OD or OS).

4 Document any pertinent information in the CD Ratio section of the OPH Posterior Exam Detail template.




Ophthalmology Enhancements to Meet ICD-10 Standards The following functionality has been included in version 8.3 to bring the Ophthalmology template set up to the ICD-10 universal standards:

Procedure Billing grid specific to Opthalmology

Today's Assessment

Impression and Plan Data

Clinical Problems related to Ophthalmology

Status fields on Ophthalmology templates

Clinical qualifiers for common diagnosis codes

Diagnosis Categories

Ngkbm Common Dx Framework practice template

Procedural Billing Grid Redesign The procedure billing grids have been redesigned for Ophthalmology to support ICD-10:

There are eight diagnosis fields available for documentation

The diagnosis Code field automatically pulls onto the Procedures module when the user submits the item to Superbill

Both a Submit Charges and Submit to Superbill button for processing the order

A read-only, selected check box displays next to Procedures submitted when the text is displayed These updates have been applied on the following templates:

Procedure Billing

Coding - OPH - Procedures/tests grid

Finalize - OPH - procedure_biling_vw_b pop-up template; the column order on the Procedure Billing grid is different from the other billing grids accessed in the other two OPH procedure templates

Today's Assessment The new standard calls for an ICD-10 compatible data grid called OPH – Today’s Assessment. The functionality of the Today’s Assessment grid is what replaces the IM Assessment and Master IM fields on the templates. The Ophthalmology version is a hide/show version of the core Today's Assessment template. All requirements regarding the core version apply with the following changes:



The Staff to Lookup Diagnosis fields do not display

The fields for Impression and Differential Diagnosis, are hidden. These two fields are housed on the OPH Assessment and Plan template for this specialty.

No Site field.

There is no link for the Assessment/Plan Details

The Common Assessments for OPH the page defaults to OPH Assessment EYE. To use a different page, click in the Common Assessments field to launch the list of Page Names.

In the Today's Assessment grid, the columns shall be:

# - the priority number of the diagnoses that has been entered for Today's Assessment. Description - full ICD description (not a user-defined or SNOMED description) Code - ICD-9 or -10, based on the encounter date and indicator Side - takes the place of the Site field on the Core Today's Assessments; displays in the grid if

one of the following is selected by the provider: blank line

OD

OS

OU

right

left

bilateral

To add an assessment:

1 Create a new encounter for an Ophthalmology patient.

2 Set the Visit Type to Office Visit. 3 Go to the Provider tab.

Note: This is the Ophthalmology version of the SOAP template.

4 On the Assessment/Plan panel, click Add.

The Add or Update Assessment template launches in the My Plan tabbed set.

Note: The OPH version of the Assessments tab includes a Side field and does not include the fields for Impression and Differential Dx in the relational box. These two fields are housed on the OPH Assessment and Plan template for this specialty. The Common Assessments for OPH the page defaults to the OPH Assessment EYE page. To use a different OPH common page, click in the Common Assessments field to launch the list of Page Names.

5 Enter a Status if required.

6 In the Side field, select a value or the top, blank row to free text an entry.

7 Click Add/Update to populate the next row in the Today’s Assessment grid.




9 Providers can select the newly entered assessment row to continue documenting the Inspection, Plan, etc.

Note: The Edit button launches the Assessments tab to enable a new or updated diagnosis selection.

Impression and Plan Data The most evident change is how the Impression and Plan data is being placed into the generated document. The data was being moved to the document based on the IM Assessment fields, allowing only eight of the items to be pulled onto the document. The existing macros have been revised to a stored procedure macro that communicates between the Order and Patient Dx tables in order to identify and display the data as it should appear in the Ophthalmology document.

On the OPH - Assessment/Plan template, users are able to view the Impression and Plan summary grids, as well as links to access other templates and modules in order to document patient information. The OPH - Assessment Plan template includes the Today's Assessment grid in place of fields that appeared in previous versions of the NextGen KBM.

To access to the OPH - Assessment Plan template:

1 Create a new encounter for an Ophthalmology patient.

2 Set the Visit Type to Office Visit. 3 Go to the Provider tab.

Note: This is the Ophthalmology version of the SOAP template.

4 Go to the Assessment/Plan panel.

5 Click Assessment to launch the OPH Assessment/Plan template.

6 Click Add to Today’s Assessments button.

7 Highlight a row in the grid to add other pertinent data (Side, Condition, etc.)

8 Type Impression details.

9 Select Quick Plan.



10 In Return to clinic field, select a value from the OPH Return Days list.

11 Click the Add to Grid button.

Note: Because of the space limitations within the fields, the Diagnosis Description is not included in the Impression column; the Diagnosis Description moved over the third position in the grid so that it is immediately apparent what diagnosis the summary is documented against. As with any other grid, users can drag and drop the columns to suit their individual preferences.


13 On the Additional Navigation panel, click the Generate Note icon.

Note: Where previously the impression and plan printed on separate lines, it is now displaying together in a grid format (similar to how it appears for all of the other specialties) with Assessment, Impression, Plan as separate rows.

If there is more than one summary, a blank row separates no. 1 from 2, etc.

Qualifiers for Clinical Content ICD-10 codes encompass a higher level of detail than those available in the ICD-9 set. These details can be seen in descriptors, or “qualifiers” in the ICD-10 descriptions for all of the diagnosis codes. A list of the most commonly used diagnosis codes (provided by the American Academy of Professional Coders) was used to identify the top 50, hard-coded diagnosis codes for Ophthalmology in the NextGen KBM. The qualifiers for these diagnosis codes have been placed on the templates in the form of new data fields, picklists, and values within existing lists so that providers can successfully document every patient encounter under the mandates of the ICD-10 standards..

Descriptive values for clinical content have been placed on these Ophthalmology templates:



OPH Physical Eye Exam

OPH External Exam Detail

Reference: Go to the Overview of Clinical Content Additions for ICD-10 in NextGen KBM White Paper and the NextGen KBM, ICD-10 Clinical Content Project Data, Version 8.3 Excel Workbook for complete details on the addition of clinical content in the templates.

Diagnosis Groups A practice template has been created so that default diagnosis codes can be saved for orders in a usable framework. This required the removal of all hard-coded ICD-9 codes from the existing templates. ICD-10 codes have been mapped and added for all of the ICD-9 codes used in the Common Assessments for Ophthalmology. The diagnosis information for OPH has been integrated into the Dx Groups/Reference Systems tab of the practice template called Ngkbm Common Dx Framework.

New diagnosis Groups for Ophthalmology:

OPH Office Procedure Assessments-Retina

OPH Office Procedure Assessments-Other

If no data is preloaded for a common assessment set included in the shipped package, launching that common assessment page from the new template returns the following message: The common assessment data set for this specialty has not been loaded.

The following assessment data has been preloaded for the Ophthalmology specialty:

OPH EYE and OPH EYE ASC

OPH Retina Assessment EYE

OPH Retinal Assessment RET

OPH Retinal Assessment EYE ASC

Note: The stored procedure that pulls the Common Assessments for the Ophthalmology specialty has been updated to look into the Ngkbm Eyeconfig template to determine if OPH General or Retinal displays. The NextGen Ambulatory EHR pulls the general Ophthalmology assessment for providers who are not listed.

The migration script for this update is included in the upgrade package.



Status Fields Added The way that the assessment status data is used throughout the NextGen KBM has been standardized through a new system template. The Ngkbm Dx Status Categories template allows the user to create and manage diagnosis status categories and to map statuses from the Diagnosis Statuses Master File in the File Maintenance application to specified template status fields. The associated statuses are displayed as part of the diagnoses selection during the encounter.

Note: New statuses must be added in File Maintenance after confirming with the practice interoperability expert that they are compatible with assessment data coming from an outside vendor.

In runtime, Status fields are available by picklist selection only. On Status field entry, or on auto-launch (an Ngkbm Config setting determines whether or not the Status field is required for an assessment), a new stored procedure launches to pull a list of diagnosis statuses based on the enterprise ID, practice ID, category name, and specialty.

A Status field has been added to the following templates:

Oph – Ocular Conditions Add

Oph – Ocular Conditions

These templates have hard-coded status of Chronic that on Save & Close is uploaded to the Diagnosis module. When the Clear for Add or Save & Add New button is selected, the values are removed from the fields on the gray, relational section of the templates named above. Specialty specific, diagnosis status categories and the list of diagnosis statuses are automatically preloaded.

Clinical Problems Related to Ophthalmology On the OPH Assessment/Plan, Cardiac History, and Assessment pop-up, when a problem is selected from the Clinical Problem list:

You can assign an ICD code to Today's Assessment by selecting a SNOMED problem from the Clinical Problems grid. The system will determine if there:

Is a one-to-one mapping, the mapped ICD code and Description display in the designated template fields.

Is a one-to-many mapping, a pop-up launches displaying the possible choices of ICD codes that are mapped to the clinical problem. You selects the appropriate ICD code and that ICD code and description display in the designated template fields.

Are no available ICD code mappings for that SNOMED clinical problem, a message appears stating that no mappings exist.

The diagnosis is added to the Diagnosis module and Today’s Assessment with the chronic indicator set to the same value that existed for the problem on the Clinical Problem list. If appropriate, the user can change the status of the chronic indicator by removing or adding the check mark.



Diagnosis Categories A set of diagnosis categories specific to the Ophthalmology specialty have been associated to the Diagnosis Categories Master File in the File Maintenance application. These groups allow you to select a diagnosis to be used during order placement and/or to include the code on the patient’s diagnosis for the encounter. ICD-10 equivalents have been added for all ICD-9 codes that are in the categories based on the following:

the category will display the ICD-9 codes before the ICD-10 effective date (set in File Maintenance).

Loaded ICD-10 equivalents appear in in the category after the ICD-10 effective date.

The Ophthalmology Home Templates In NextGen KBM version 8.3, Ophthalmology has three Home templates to choose as a starting point for documenting an encounter. For General Ophthalmology, there are two choices, the Home – OPH template (eyemaster_im), which uses the original 10–tab encounter workflow, and the new Home Page – OPH template (oph_home_page), which uses the new 5-tab encounter workflow.

Ophthalmology ASC and the Retina sub-specialties continue to use the same Home templates as they have in previous versions of the NextGen KBM. Ophthalmology ASC uses the ASC Home – OPH template and the original ASC 10-tab workflow, and Retina continues to use the Home – OPH template and 10-tab workflow. If the Retina provider has not been designated as such in the Ngkbm_Eyeconfig practice template, or if a generalist wants to use the Retina workflow for a particular patient, then the “Use retina workflow for this encounter" check box should be selected.

Ophthalmology Home templates can be configured in Preferences as a default template or as part of a list of Preferred templates. In this section, we will briefly discuss each of the Home templates for Ophthalmology and when to use them.

Launching the Ophthalmology Home Template When you first log into the NextGen Ambulatory EHR, you will see a blank screen unless you have configured a module such as the Inbox to open automatically. Once a patient chart is opened, a blank screen will still be displayed unless you have already configured a preferred template to open. You will have to navigate to the Ophthalmology Home template using Template Launcher, which can be opened using the icon found in the lower tic-tac-toe section of the History toolbar.

1 Click the Templates button to open Template Launcher and the Select Template dialog box. Select to show ‘All’.

2 Scroll down until you see the Home template you wish to use displayed in the list and double-click it to open the template.

Note: You can type the first letter of the template's display name on the list and the list will be refreshed to show templates beginning with the letter. For example, type the letter ‘H’ to search for "Home - OPH". This will enable you to locate your template more quickly.



In NextGen KBM version 8.1, most specialties were redesigned to use the Framework Intake template as a starting point, with a small number of specialties continuing to use a specialty home page template.

For users that will be working within a single specialty, you can set a preferred medical records template to open by default when a patient chart is opened and a new encounter is created. For users that work with more than one specialty, you can select a list of preferred templates to use as a starting point in Preferences. This has been covered previously in Chapter 1, Getting started with the NextGen Ambulatory EHR.



If you haven't selected a default medical records template, you can use Template Launcher to open the Ophthalmology Home template set you wish to use by selecting it from the list of medical records templates.

Ophthalmology Home Templates and Tabbed Template Sets in NextGen KBM Version 8.3 For Ophthalmology there are three Home templates available to users:

ASC Home – OPH (eyeasc_homescreen)

Home – OPH (eyemaster_im)

Home Page – OPH (oph_home_page)

Each of these home templates function as the starting point for documenting an encounter for each of the sub-specialties that are currently included within the Ophthalmology NextGen® KBM. It is important to understand how to choose which of these templates to use and when. Note that the display name is shown first, with the Template Editor name shown within parentheses.

Ophthalmology ASC Home Template ASC Home – OPH (eyeasc_homescreen)

This template is the Home page starting template for the Ophthalmology Ambulatory Surgical Center template set only.

When using this template, you will be taken to an Ophthalmology 10-tab template set that is used to document a surgical encounter, from pre-procedure calls to the patient to patient arrival and pre-operative nursing, to the actual OR record, post-operative nursing care and patient discharge.

The following screen capture shows how to select to open the Ophthalmology ASC Home template in Template Launcher.



The Ophthalmology ASC tabbed Template set. This tabbed template set opens to the Home tab, and is launched by selecting “ASC Home – OPH” in Template Launcher or configuring eyeasc_home as a default or preferred template in Preferences.

The Ophthalmology Home Template for General and Retina Home – OPH (eyemaster_im)



This template is the Home page starting template for General Ophthalmology and Retina specialties, when using the 10-tab template set workflow. This template is the Home tab of the original Ophthalmology 10-tab template set used in earlier versions of the NextGen KBM (7.9.x/ 8.0.x/ 8.1.x).

In NextGen KBM version 8.3, users can continue to choose to use this template as their starting point and document the encounter using the original Ophthalmology 10-tab template set found in earlier versions (7.9.x/ 8.0.x/ 8.1.x) of the NextGen KBM.

If users choose to document a patient encounter using the original 10-tab template set, starting with this template, they must continue to use this tabbed template set to document the entire encounter. There is no ability to change to using the new Ophthalmology 5-tab template set based on the 8.x Framework in the middle of documenting an encounter.

Providers cannot create a new clinical encounter that is separate from the billable encounter created by the NextGen® Practice Management without also creating billing problems. If users decide that they would like to use the new 5-tab template set, they must decide this before they begin to document a clinical encounter.

To use this template and the 10-tab template set for Retina workflow, users must select the “Use Retina workflow” check box unless they have been designated in the ngkbm_eyeconfig practice template as a Retina provider. This check box is located at the bottom left corner of the Home – OPH template, seen as the Home tab of the 10-tab template set.

Caution: In NextGen KBM version 8.3, there are now two tabbed template sets available for use by General Ophthalmology. If users choose to document a patient encounter using the original 10-tab template set, they must use this tabbed template set to document the entire encounter. This is also true if users decide to use the new 5-tab template set. Once you begin to document an encounter, you cannot change which tabbed template set you use. There is no ability to switch between template sets in the middle of an encounter. To begin using the other tabbed template set, you must first create a new encounter. A new encounter for a patient in the office is generally created by the front desk, and accessed by opening the patient's chart through the Inbox.



The following screen capture shows selecting the original Ophthalmology Home template (Home - OPH) in Template Launcher, to launch the original 10-tab template set.



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In NextGen KBM version 8.3, the Retina Ophthalmology templates remain with the familiar 10-tab template set for Ophthalmology. This template set is launched by selecting the “Home – OPH” template listed in Template Launcher in the History toolbar or configured as a preferred medical records template in Preferences on the Template tab.

In order to use Retina workflow, certain configuration prerequisites must be performed, including setting up a provider as a Retina specialist or selecting to use Retina workflow on the Ophthalmology 10-tab template set.

Configuration Prerequisites for Retina Workflow In order to use Retina Ophthalmology workflow, the provider must be set up as a Retina specialist in Ophthalmology. This will set up Retina workflow on the templates when the provider is selected. When using Retina workflow, a Retina specialist must be selected as the provider from the Provider drop-down list box in the NextGen Ambulatory EHR application toolbar before beginning to document patient encounter information.

Configure a Provider as a Retina Specialist

1 Launch the Ngkbm_Eyeconfig pratice template Log into NextGen Ambulatory EHR Click on File menu > System/Practice Templates submenu > Practice tab > select Show “All” >

double-click on “Ngkbm_Eyeconfig” to open. 2 At the Ngkbm_Eyeconfig system template, set up the provider

a) Right click on the Provider Specialty data grid and select “Add new” from the drop-down menu. The Ophthalmology Provider Specialty pop-up will be launched.

b) Click in the Provider Name field to launch the Provider_Mstr list. Click on the provider name to select, and then click on OK. The Provider_Mstr list will close.

c) Click in the Specialty field to launch the Eyespecialty picklist. Click on “Retina” to select.

d) Click on the Save pop-up toolbar button.

e) If more than one user is to be set up as a provider with Retina specialty for Ophthalmology, click on the “Clear for Add” button and repeat steps 2a – 2e.

f) When you have finished, click on the Close button.

g) Close the Ngkbm_Eyeconfig template by clicking on the Close template toolbar button.

Reference: The Ngkbm_Eyeconfig practice template has been covered in detailed in Chapter 2 of this document.

C H A P T E R 4

Retina Ophthalmology Workflow Basics

Chapter 4 Retina Ophthalmology Workflow Basics


Important: A provider can either be a General Ophthalmologist or a Retina specialist, but not both at the same time.

Use Retina Workflow Check Box (Temporary Change from General Workflow)

To use Retina workflow temporarily as a Generalist Ophthalmology provider, when you first launch the Ophthalmology 10-tab template set, you must first click on the “Use retina workflow for this encounter” check box to select it. This check box is found at the very bottom left corner of the original Ophthalmology Home template (eyemaster_im). This check box will temporarily allow a Generalist to launch the Retina workflow with access to the Retina HPI and Retina drawing backgrounds, and will also directly launch the Retina exam templates.



Note: Remember to return any providers set as Retina specialists to their original settings if they are not going to continue as Retina specialists only.

Retina Ophthalmology Workflow Starting Point Retina Ophthalmology workflow starts with selecting a provider who is a Retina specialist and opening the correct Ophthalmology Home template.

1 Log into the NextGen Ambulatory EHR.

2 Open the patient chart from the Inbox if the patient is scheduled for an office visit.

3 Before opening the Ophthalmology template set: Verify or select your Location in the main toolbar. Select the correct Provider in the main toolbar.



4 Create a new encounter using the New button on the History toolbar if the patient is not being seen in the office today. (If the patient has an appointment today, the front desk should be opening a billable encounter for the day.)

5 Open the Ophthalmology Home template (seen listed as “Home - OPH” in Template Launcher.) If the Ophthalmology Home template is not configured to be your default medical records

template in Preferences: a) Click on the Template Launcher icon in the bottom section of the History toolbar.

b) Select to display all medical records templates.



c) Double-click on “Home - OPH” to open the template.



Caution: If you have selected a provider who has been setup as a Retina specialist on the ngkbm_eyeconfig practice template, you will not have to select the retina workflow check box. Those retina specialists who only see retina patients should be set up as a retina specialist in the ngkbm_eyeconfig practice template to decrease their clicking.



This chapter describes the workflow of an office visit encounter using the Retina workflow on the Ophthalmology 10-tab template set. Retina Ophthalmology uses the Home – OPH template (eyemaster_im) as the starting point. This template is seen as the Home tab of the 10-tab template set.

Retina Ophthalmology Basic Workflow Outline For most office visit encounters in Retina Ophthalmology, the following is a basic outline of workflow for the technician and the provider. This workflow will be covered in greater detail beginning with technician workflow on the Home – OPH template.

1 Select location and provider in the top application toolbar.

2 Open a patient chart.

3 Open the Home – OPH template, which is part of the Ophthalmology 10-tab template set.

4 Technician workflow follows the lower row of 5 template tabs. Home CC-HPI-ROS History Tech Exam Testing

5 Provider workflow follows the upper row of 5 template tabs. Provider Start Exam Procedures Plan Coding

Once the Ophthalmology 10-tab template set is open, the History tool bar on the right side of your screen closes and the expanding left navigation bar becomes hidden. Hovering over the left Navigation will cause it to expand. Clicking on the History button in the application main toolbar will open the History toolbar.

Information is organized on different tabs, which are displayed across the top of each template page. Click on the tabs at the top to navigate to different sections of the Ophthalmology office visit template set. Note that the Technician workflow follows the lower row of tabs.

C H A P T E R 5

Retina Ophthalmology Office Visit Workflow

Chapter 5 Retina Ophthalmology Office Visit Workflow


Patient Information Bar With NextGen KBM version 8.3, the Patient Header was redesigned and made separate from the actual templates where encounter information is documented. The Patient Header is now called the Patient Information Bar and can be seen above all main templates. The Patient Information Bar can be viewed in an expanded format that provides more details about the patient, as well as links to other important templates and pop-ups, or as a thin band in a “collapsed” format showing only key information and providing greater screen area to display templates.

The Patient Information Bar can be configured in File Maintenance, in the EHR System Master Files in the Practices folder under Preferences.

Key Details about the Patient Information Bar 1 The Patient Information Bar is found as a section band above the templates, and is now separate

from the templates instead of part of them.

2 Previously known as the Patient Header, this feature is now called the Patient Information Bar, and can be configured in NextGen® File Maintenance.

3 The Patient Information Bar can be displayed in two formats: expanded format with a collapse Up arrow icon in top right corner

a narrow collapsed format with an expand Down arrow icon in the top right corner

Information and Links Found on the Patient Information Bar The Patient Information Bar displays certain demographic and medical information, and provides links to other templates, pop-ups, and modules.



The Patient Information Bar can be configured in File Maintenance, in the Master Files, System EHR in the Practices file under Preferences.

The top section allows the practice to select which 3 (out of 7) items they wish to display on the Patient Information Bar. In the example above, Insurance, Nickname, and NextMD Indicator were selected.

The bottom section allows for either putting links to certain demographic templates on the Patient Information Bar, and/or putting discrete information from these demographic templates on the Patient Information Bar. In the example above, Emergency phone number, Pharmacy name, and Work phone number were selected from the Patient Demographics template to display on the Patient Information Bar. In File Maintenance, clients can choose to configure up to three templates to launch and their displayed links, and up to three template fields. These can only be demographic fields.

Demographic and Medical Information The Patient Information Bar displays certain basic demographic and medical information about the patient. For some types of information, such as Medications, the label is an active text link that will launch the corresponding module or template when clicked.



Information displayed directly on the Patient Information Bar includes:

Patient name

Gender

Date of birth

Age

Photo

Address

Telephone or contact information

PCP

Referring provider

Rendering provider

Referring Provider - launches the Patient Provider template, where the details for the patient's providers can be viewed or documented, including primary care provider (PCP), referring provider, other specialists and rendering provider; the names of the patient's providers are displayed in the Patient Information Bar if they have been documented on the template. In most cases, this information will have already been entered when the patient has checked in.

Allergies – indicates the number of allergies documented for the patient; acts as a link to launch the Allergy module; hovering over will display a list of allergies documented for the patient

Problems – indicates the number of problems documented for the patient; acts as a link to launch the Problem List section of the Problems module; hovering over will display a list of chronic conditions/active problems/tracked problems documented for the patient

Diagnoses – indicates the number of billing diagnoses that have been documented for the patient; acts as a link to the Billing ICD List section of the Problems module; hovering over will display a list of ICD-coded diagnoses documented for the patient

Medications – indicates the number of medications that have been documented for the patient; acts as a link to the Medications module; hovering over will display a list of active medications documented for the patient

Alerts The Alerts indicator is a button that turns red in color when there is an alert that has been documented for the patient on the Alerts pop-up. The Alerts button launches the Alerts pop-up template. (When there are no alert items, the Alerts button is gray with black lettering. When there are alert items present, the Alerts button is red with white lettering.)



The Alerts button is on the left side of the Patient Information Bar. Clicking this button will launch the Alerts pop-up template. Currently, no alert items had been documented for the patient.

The Alerts template with an Ophthalmology alert entered.

To view or document Alerts:

Note: Not all alert items will be documented or followed by all specialties.

1 Click the Alerts button to open the Alerts pop-up template.

2 Select any items in the top half of the template by selecting their corresponding check boxes.

3 Document Suicide/Homicide Risk, if appropriate Click the Suicide/Homicide Risk active text to open the Safety Risk pop-up template. Select answers to questions by selecting the appropriate options. Enter comments by clicking in the Comments field and typing free text. Click Save & Close.



The Suicidal/Homicidal risk assessment will be saved to the data grid. 4 Document Ophthalmology alerts

Click in the OPH Alerts field above the grid and select from the picklist or click Close to close the picklist and type free-text..

Click in the Note field and type a brief note. Click the Add button to add the alert to the grid.

5 Document Cardiology alerts (Not used by Ophthalmology. Optional for some specialties.) Click the Add button below the grid on the right to open the Card Alert DataEntry pop-up

template. Select the option Standard or Important to open a dbpicklist of alerts. Select an alert from the dbpicklist. If the start date is different from today’s date, click the Start Date active text and select a date

from the Calendar. To enter a stop date, click the Stop Date active text and select a date from the Calendar. Click Accept to add the alert to the grid.

6 Additional comments can be entered by clicking in the Additional Comments field and typing in free text.


Links to Other Templates The Patient Information Bar displays certain demographic and medical information, and can provide links to other templates and modules. Links to other templates have to be configured in File Maintenance, in the System Master Files for EHR, in the Practices file under Preferences.

Clients have some flexibility in choosing up to three demographic templates to be launched and their displayed active text, and up to three demographic template fields and their displayed labels.



The system is shipped with links to the following templates:

OBGYN Details (female patients only, ages 12 and older) – launches the OBGYN Synopsis template.

Specialty-specific Summary - launches the specialty-specific summary template, if there is one.

Not all specialties have specialty-specific summary template. Ophthalmology does not.

Sticky Note – launches the Sticky Note free text Patient Information Comments pop-up template which is used to document information using free text that will not appear in generated documents, but will copy forward from visit to visit unless it is erased.



Referring Provider – launches the Patient Providers pop-up template where information about the patient’s providers can be viewed, edited or added. On this template, it can be indicated which of these providers should be copied on the chart note or on the consult thank you letter.



HIPAA – launches the HIPAA Disclosure Information pop-up template where details for health information disclosure for the patient are documented.



Advance Directives – launches the Advance Directives pop-up where details for advance directives, durable power of attorney, and healthcare proxy for the patient are documented.



Screening Summary – launches the Screening Summary pop-up where summary information for pain, signs of domestic violence functional status, lead, social history (nutrition, tobacco, caffeine, alcohol, drug), counseling, and screenings performed (PAP, hearing, mammogram) for the patient are documented. This template is often used by practices that are surveyed by The Joint Commission. Documenting information on this template will populate the corresponding fields in the related templates, and vice versa. (These fields are shared.)

Navigation Buttons On the far left side of the Patient Information Bar, you will find a set of Navigation buttons that are also found at the top of the Expanded Left Navigation pane:

1 Navigation buttons that are also found at the top of the Expanded Left Navigation pane: Patient Tracking – launches the Patient Tracking pop-up. (Button #1) Patient Communication - launches the Patient Communication tabbed template set formerly

known as “Telephone Call” templates. (Button #2) To Do /Tasking - launches the To Do pop-up which will launch the Attach pop-up for Tasking

and then the Tasking template when saved. (Button #3) Mail – launches the Attach pop-up for attaching a template to forward by email to one of the

logged in provider resources. Note that email must be configured. (Button #4)



2 Navigation buttons found on the far left of the expanded Patient Information Bar are the same buttons found at the top of the Expanded Left Navigation pane.

The Patient Tracking pop-up launched using the toolbar button found at the top of the left

navigation pane and on the left side of the Patient Header. (Button #1 Tracking.)



The Patient Communication pop-up launched using the toolbar button found at the top of the left navigation pane and on the left side of the Patient Header. (Button #2 Communication.)

The “To Do” pop-up launched using the toolbar button found at the top of the left navigation

pane and on the left side of the Patient Header. (Button #3 Tasking.) This pop-up is followed by the Attachment pop-up and Tasking.



The Tasking pop-up opens after the Attach pop-up has been closed. The Tasking pop-up is preceded by the “To Do” pop-up and the Attach pop-up when the toolbar button at the top of the left navigation pane or the Patient Header is clicked. (Button #3 Tasking.)



In this section the intake workflow for a patient encounter that begins on the Ophthalmology Home (Home-OPH) template (eyemaster_im) will be discussed. This Intake begins when the patient arrives at the practice, and can be completed by office staff, nursing or the technician depending on the practice. Because of the organization of Ophthalmology workflow across the 10- tab template set, the technician has generally been the individual whose role it is to begin documenting the encounter when the patient arrives.

Ophthalmology Home The Home – OPH template (eyemaster_im) is primarily used for displaying historical information for the patient that is relevant to Ophthalmology. Patient information should be reviewed and updated, or entered if this is an initial encounter.

The following information can be found on the Ophthalmology Home template:

General patient information

Patient providers

Advanced Directives

Health Monitor section specific to Ophthalmology

Vision Correction

Visual Acuity

IOP

Allergies

Ocular Medications

Ocular History

Review Patient Information on the Home Template All information displayed will be pulled from other locations and templates, including demographics, the Patient Providers template, Health Monitor, and historical Ophthalmology exam findings.

Section Description Patient patient’s name

D.O.B. patient’s date of birth

C H A P T E R 6

Technician Workflow

Chapter 6 Technician Workflow


Section Description Gender patient’s gender, found to the right of DOB

Age patient’s age

Alerts Alert button in Patient Information Bar will be red if there are any alerts to be checked for the patient. Alerts can be viewed and/or documented by clicking the button and following the procedure described in the Patient Information Bar section to document alerts for the patient.

First Seen date the patient was first seen by the practice; will be blank if this is first encounter with new patient

PCP patient’s primary care provider

Referring referring physician

Specialist specialist provider

Appointment Requests/Orders

grid that will display requests and orders from last visit

Health Monitor review this section for items with a red date indicating the item may be due

Vision data grid displaying history of visual acuity measurements; click the Graph button to display information in a graphical format

IOP data grid displaying history of intraocular pressure measurements and target values; click the Graph button to display information in graphical format

Allergies data grid displaying list of current active allergies

Ocular Medications

data grid displaying list of ocular medications, can select to see current active or inactive medications

Ocular History data grid displaying list of past ocular procedures and diagnoses

Enter or Update Information on the Home - OPH Template Documenting an office visit encounter begins at the top of a template, and goes across and down. Certain elements can be reviewed or documented from the Patient Information Bar. The remaining areas of information can be reviewed and, in some cases updated, in the various sections that are found on the Home template.



First Seen To document First Seen:

Click in the field and select from the Calendar pop-up template.

This value is carried-forward and will only have to be entered one time.

Correction To document Correction:

Glasses

a) Indicate whether patient wears glasses by selecting the check box No or Yes for GL wearer.

b) If yes wears glasses

Enter type of glasses by clicking in the Type field and selecting from the picklist.

To enter a type not listed, select the top blank line and manually type in the field using free text.

Enter number of years worn by clicking in the Years field and enter the number using the onscreen numeric keypad.

Contact Lenses

a) Indicate whether patient wears contact lenses by selecting the check box No or Yes for CL wearer.

b) If yes wears contact lenses

Enter type of contact lenses by clicking in the Type field and selecting from the picklist.

To enter a type not listed, select the top blank line and manually type in the field using free text.



Enter number of years worn by clicking in the Years field and enter the number using the onscreen numeric keypad.

Advanced Directives The Advanced Directives pop-up is used to document and review advanced directives details for the patient, including details for supportive care, power of attorney, and healthcare proxy. When Advanced Directives information has been documented for the patient, the Advanced Directives active text link will appear pink in color with a solid wing-ding to indicate that information exists on the pop-up template. A bright yellow Exclamation Mark icon will also appear.

To view or document Advanced Directives:

1 Click the Advanced Directives active text link to open the Advanced Directives pop-up template.

2 Review the Advanced Directives and Status section

a) Date reviewed - If the patient’s advanced directives have been reviewed before, the Date reviewed field at the top left of the template will be populated automatically. Selecting a Status will automatically update this field to reflect the current encounter date.

b) Time reviewed - If the patient’s advanced directives have been reviewed before, the Time reviewed fields at the top left of the template will be populated automatically.



c) Discussed time - The Discussed time field is a counter that will reflect the number of times Advanced Directives have been discussed with the patient. Selecting a Status will automatically increment the displayed value by 1.

d) Effective date of directive – If the patient’s advanced directives have been reviewed before and documents exist and are on file, the Effective date of directive field will be populated with the date advanced directives were recorded. Enter an Effective date by clicking in the field and selecting from the Calendar pop-up template.

e) Documents – Select the check box to indicate the type of document and its disposition

Living will

Scanned advance directive document on file

Location of document – Click in field and manually type in free text.

f) Verified by – Select the option to indicate who/how advanced directives were verified

Verified with patient and is current

Verified with family only; Enter Family member name and Relationship

Verified by medical records only

g) Status - Select the Status “Reviewed” or “Reviewed, detailed document” by selecting the appropriate option. When the Status is selected, the following will happen:

Date reviewed field will display the current encounter date

Time field will reflect the current system time

Discussed time field displayed value will be incremented by 1

3 Directives on File section – Click the check boxes or options to select the appropriate response(s) for items found in the Directives on File section.

a) Select the check box to document “None” or “Refused”.

b) Select the option to indicate “No” or “Yes” for different interventions and supportive care, such as DNR (Do not resuscitate), IV fluid and support, and blood/blood products.

c) Other directives – Click the check box to select and manually type in using free text.

4 Durable Power of Attorney – Click the check box to select and complete information in the section to document details.

5 Healthcare Proxy – Click the check box to select and complete information in the section to document details.

6 Comments – Enter any additional comments by clicking in the field and manually typing free text.




Ophthalmology Patient Providers The Patient Providers – OPH pop-up template (eye_ret_patient_providers) is used to document the patient’s primary care provider, referring provider and reason for referral, along with any specialists and other providers. This is also where you document which of the patient’s providers should be sent letters. Patient providers can be populated from NextGen® Practice Management or they can be documented on this pop-up template.

Note: The Patient Providers – OPH pop-up template (eye_ret_patient_providers) is an Ophthalmology specific medical record pop-up template that is similar to but different from the Core Patient Providers demographic pop-up (patient_providers) which is linked to from the Patient Information Bar by clicking the Referring Provider active text.

To view or document Ophthalmology Patient Providers:

1 Click the Patient Providers active text link to open the Patient Providers - OPH pop-up template (eye_ret_patient_providers).

2 Send referral letter



You can send a referral letter to the patient’s primary care provider and to another referring provider, if these providers are not the same. However, the referral letter can only be addressed to one of the providers, the PCP or the Referring Provider if different from the PCP. The “Address letter to” radio button for each provider cannot be selected both at the same time.

If you want to send more than one letter, use the Send Letters section to select additional providers to receive letters with a personalized greeting.

a) PCP – The Primary Care Provider (PCP) will be automatically populated from NextGen Practice Management, if it has been documented for the patient.

If a PCP is not displayed for the patient, you can click in the PCP Provider field and select from the db picklist.

Select to send a referral letter to the PCP by clicking the PCP check box.

Click the “Address letter to PCP” option button to send a referral letter to the patient’s PCP with a personalized greeting. (The referral letter can only be addressed to one provider, the PCP or the Referring Provider if different from the PCP. However, on the Document Library-OPH template, you can address Leter1 to one person and Letter2 to another.)

b) Referring Provider – The Referring Provider will be automatically populated from NextGen Practice Management, if it has been documented for the patient.

If a Referring Provider is not displayed for the patient, you can click in the Referring Provider field and select from the db picklist.

Select to send a referral letter to the Referring Provider by clicking the Referring Provider check box.

Click the “Address letter to referring Dr.” option button to send a referral letter to the patient’s Referring Provider with a personalized greeting. (The referral letter can only be addressed to one provider, the PCP or the Referring Provider if different from the PCP.)

Note: You can select to send the referral letter to both the PCP and the Referring Provider if they are not the same, but you can only select one of these providers to have a personalized greeting.

3 Reason for referral – Select the appropriate reason for referral option: Consultation, Evaluation and Treat, Evaluation, or Treat.

4 Comments – Enter any comments by clicking in the Comments field and typing in using free text.

5 Send Letters section

a) Letters can also be sent to a specialist and copies sent to up to three other providers.

Click in the Provider field and select a provider from the db picklist for Specialist and/or “CC Provider 1”, “CC Provider 2”, “CC Provider 3”

Click the corresponding Specialist and/or CC Provider check box to select to send a letter.

Click the corresponding “Address letter to” option button to select to address the letter with a personalized greeting.




Health Monitor The Health Monitor section for Ophthalmology follows testing and procedures of interest to ophthalmologists and the dates they were last performed for a patient. Timeframes for Ophthalmology testing and procedures are configured on the ngkbm_eyeconfig practice template, as described previously in Chapter 3. The date a test was last performed will be displayed in the date field for that test. If the date the test was last performed is within the timeframe defined on the ngkbm_eyeconfig practice template, it will appear in black font. When the test becomes past due, the date last performed will appear in red font to alert clients that the test is due to be performed again.

For Ophthalmology, the following tests and procedures are followed:



CL fit

Dilated exam

FA

Gonioscopy

ICG

IOP check

OCT

ONA/GDX/HRT

Pachymetry

Photos

Refraction

VF

If this information has been previously documented for the patient, it will be carried forward. When one of these items is completed during the course of a visit, the date of the visit will automatically populate the appropriate date field. Otherwise, you can document this information by clicking in the appropriate fields and making a selection. Dates are entered using an onscreen numeric calendar.

Vision (Visual Acuity) Visual Acuity information will be displayed in the Vision data grid, showing the history of past values for the patient.



Vision - past visual acuities

Visual Acuity information can be viewed in graphical format by clicking on the corresponding Graph button to open the Ophthalmology Graphs pop-up template (oph_eye_graphs). Graphs will plot values over time.

Historical Visual Acuity information can be added by double-clicking on the grid or updated by

double-clicking on a row in the grid with data to open the Visual Acuity – OPH pop-up template.

a) After entering or updating visual acuity information, click the Save pop-up toolbar button.

b) To add another record, click the “Clear for Add” pop-up toolbar button.



c) If you have finished documenting information, click the Close pop-up toolbar button.

IOP (Intraocular Pressure) Intraocular Pressure information will be displayed in the IOP data grid, showing the history of past values for the patient.

IOP - past Intraocular Pressures

IOP information can be viewed in graphical format by clicking the corresponding Graph button to open the Ophthalmology Graphs pop-up template (oph_eye_graphs). Graphs will plot values over time.

Historical IOP information can be added by double-clicking on the grid or updated by double-clicking on a row in the grid to open the IOP Extended – OPH pop-up template.

a) After entering or updating visual acuity information, click the Save pop-up toolbar button.

b) To add another record, click the Clear for Add pop-up toolbar button.



c) If you have finished documenting information, click the Close pop-up toolbar button.

Allergies (Brief)

Caution: Detailed information about documenting Allergies can be found in the section of this document covering the History tab template. After documenting allergies on the History template, finish by selecting one of the following options: “Allergies reviewed, no changes” or “New allergies added this encounter”. If JCAHO Standards have been enabled on the ngkbm_config practice template, you will not be allowed to navigate away from the History tab template until this has been done.

Current allergies information for the patient can be viewed on the Home - OPH tab template. While allergy information can be reviewed or updated from the Home template, the History tab template is the preferred place to do this.

Allergy information will be displayed in a data grid.

If JCAHO Standards have been enabled, you will have to document that allergy information was reviewed or reviewed and updated on the History tab template before you will be able to navigate away from the History template.

New allergy information can be added, or existing information can be updated, by double-clicking on the Allergy grid to launch the Allergies Module.

After adding or updating allergy information, save and close the Allergies Module.



Ocular Medications Ocular medications will be displayed in a data grid.

Existing ocular medication information can be viewed in detail by double-clicking on a row in the grid with data to open the Ophthalmology Medications pop-up template (oph_ophthalmic_meds).

New medications must be added using the Medication Module. (This can be done on the History tab template.)

When you have finished viewing or updating information, click the Close pop-up toolbar button.



Ocular History Ocular history will be displayed in a data grid.

New ocular history information can be added by double-clicking on the Ocular History grid or existing information updated by double-clicking on a row in the grid with data to open the Ocular History – OPH extended pop-up (mngOcularHistory).

After entering or updating ocular history information, click the Save pop-up toolbar button.

To add another record, click the “Clear for Add” pop-up toolbar button.

If you have finished documenting information, click the Close pop-up toolbar button.

Tech Signoff - Home When the setting for Technician and Provider sign-off check boxes has been enabled on the ngkbm_eyeconfig practice template, each of the main tabbed templates will have check boxes at the top used for visually cuing the technician and the provider to review the template and sign-off on it by clicking the check boxes. These check boxes will appear on the office visit tabbed template set by default. The ngkbm_eyeconfig setting for "Provider and Technician sign-off check boxes" with the option to "Hide" these check boxes must be checked if you do not wish to use this function.



If sign-off is configured, click the Tech Signoff check box found at the top of the template to select. The currently logged in user and the system date and time will populate the read-only fields at the top of the template, and the tab will show a check box with a check mark.

Reference: Please refer to the section covering Ophthalmology configuration on the ngkbm_eyeconfig practice template found in the chapter "Getting Started with Ophthalmology in NextGen KBM" of this document.

Navigate to the CC-HPI-ROS Tab After reviewing and updating all information on the Home template, click the CC-HPI-ROS tab to go to the next step, documenting Chief Complaint, History of Present Illness, and Review of Systems.

Ophthalmology CC-HPI-ROS After completing encounter review and documentation on the Home tab, the intake workflow for a patient encounter continues on the Ophthalmology CC-HPI-ROS tab template (eyeChiefComplaint). For the Retina specialty, the Retina HPI pop-up template (retina_hpi) can be used to document HPI information instead of the HPI section on this tab template. A link to the Retina HPI template is found at the top left of the CC-HPI-ROS tab template.

The CC-HPI-ROS – OPH template is used for documenting chief complaint, history of present illness, and review of systems information. This template is seen as the CC-HPI-ROS tab of the 10-tab Ophthalmology template set.

The following information can be found on the Ophthalmology CC-HPI-ROS template:



General patient information – type of patient, exam type, etc.

Health Monitor section specific to Ophthalmology

Patient providers – active text link to open the Ophthalmology Patient Providers pop-up template

Retina HPI – active text link to open the Retina HPI pop-up template

History of Present Illness completed by

Chief Complaint (up to three can be documented)

Review of Systems

For the Retina Ophthalmology specialty, general patient information and review of systems is documented on the CC-HPI-ROS – OPH template. HPI information can be documented in the General HPI section on the CC-HPI-ROS - OPH tab template or it can be documented on the specialty-specific Retina HPI pop-up template. After documenting information on the Retina HPI pop-up template, the concatenated information will be displayed on the CC-HPI-ROS – OPH tab template. ROS information is documented at the bottom of the CC-HPI-ROS – OPH tab template after you have completed HPI.

General Patient Information The general information area found at the top of the CC-HPI-ROS – OPH tab template displays some information that has been previously documented, as well as information that needs to be documented.



Patient Type - Indicate patient type by clicking on the appropriate check box: New, Established (Est.), Consult, or Post Op. This is for coding purposes.

Exam type – Enter by clicking in the field and selecting from the picklist. To enter a value not included in the picklist, select the top blank line and manually type using free text. This is not a mandatory field, but selecting an item from this list will enter data that can be reported on. This can be useful if the practice wants to know how many patients presented for one type of exam, for example.

Referred by – fields will display patient’s referring provider if previously documented at the Ophthalmology Patient Providers pop-up template; a link to the Ophthalmology Patient Providers pop-up template is also present

Requesting reason – Enter by clicking in the field and selecting from the picklist. To enter a value not included in the picklist, select the top blank line and manually type using free text.

Eye – Click in the field and select right eye, left eye, or both eyes

Reason for referral – will display reason previously selected on the Ophthalmology Patient Providers pop-up; can select by clicking on the appropriate radio button: Consultation, Evaluation and treat, Evaluation, Treat

Referral comment – Enter by clicking in the field and typing free text

Historian - Enter by clicking in the field and selecting from the picklist. To enter a value not included in the picklist, select the top blank line and manually type using free text.

Insurance – these are read-only fields that will display patient insurance previously documented in NextGen Practice Management or on the Patient demographics templates

Health Monitor (Summary) The Health Monitor section is found on the CC-HPI-ROS – OPH tab template in the upper right. The Ophthalmology tests and procedures being followed will display the last dates these tests and procedures have been performed for the patient. Again, it is possible to update these dates by clicking in Date fields and selecting a date from the Calendar pop-up.



Retina History of Present Illness (HPI)

Documenting on the Retina Ophthalmology HPI Template

To document HPI information during a Retina encounter using the Retina History of Present Illness - OPH pop-up template, click the Retina HPI active text found above the "History of present illness completed by" field in the upper left of the CC-HPI-ROS – OPH tab template.

1 Follow up reasons and Eye – These fields are only completed for a follow-up visit for the Retina specialty. Each Follow up reason field has a corresponding Eye field. You can document up to two follow-up reasons and the eye(s) they apply to by clicking in the field and selecting from a picklist. To enter a reason not listed, select the top blank line and manually type in free text. These fields will not display if the encounter has been designated as a new encounter on the CC-HPI-ROS tab template.

2 Referred for and Eye – These fields are found in the top right corner of the template, and will display information previously documented on the CC-HPI-ROS – OPH tab template. You can enter or change this information by clicking in the fields and selecting from picklists. To enter a reason not listed, select the top blank line and manually type in free text.

3 Complete the appropriate HPI questions



a) HPI details can be documented beginning with the left side column of fields, starting with the “The patient reports” field.

Most information can be selected from picklists.

To enter details not seen in a picklist, select the top blank line and manually type in using free text.

For those picklists without a blank line, you will not be able to use free text.

b) The first seven fields on the left side will have a corresponding field on the right to identify the Eye. For example, the left side field “The patient reports” is associated with the corresponding right side field “Eye”.

c) Once you click in the field on the left and select from the picklist, the picklist for the associated field on the right will automatically open. If you manually type in a value, if there is a right side field, you may have to launch the right side picklist by clicking in the field.

d) Only the details that apply to the patient need to be completed. For example, if the patient has not had recent surgery, you do not have to make a selection for the fields referring to a surgical procedure.

4 Complete appropriate medical questions On the lower right side of the Retina HPI pop-up is a short list of medical questions for

patients with diabetes and for patients with AMD. 5 Build the note - After completing all of the appropriate questions, click the Build Note button

found in the lower left of the template. The final result of all of your selections will be a descriptive HPI in a concatenated paragraph

format. Clear - To clear out the HPI note after you have generated it, click on the Clear button above

the Note field on the right. Clear All - To clear out all HPI fields, click on the Clear All button in the top right corner of the

template.



6 After the HPI has been completed, click Save & Close. The Retina HPI pop-up will close, and the Retina HPI note will be displayed in the first column of Chief Complaint/HPI in the Comments field, with the CC1 field displaying “From retina cc/hpi”.

Completing the Retina HPI on the CC-HPI-ROS Template

After you have documented the Retina HPI, the final concatenated note will be displayed in the Comments field for CC1, the first column of Chief Complaint/HPI fields.

1 There are two more HPI related details to complete, which are found in the General HPI section

a) Denies – Click the Denies button to open the Patient Denies picklist. This is a multi-select picklist so to close it, click Close after you have made all of your selections. Selections will be added to the Comments field and the concatenated HPI note.

b) Previously Treated – Click on the Previously Treated check box to indicate that the patient was previously treated for the complaint. Document When and By whom using the fields below the check box.



2 Click the Add/Update button below the Previously Treated fields when you have completed documenting this section to add this information to the HPI above and to add the completed HPI to the Chief Complaints and HPI grid.

Review of Systems (ROS) Review of Systems can be found at the bottom of the CC-HPI-ROS – OPH tab template, below the Chief Complaint/HPI section.

There are three ways to document ROS when using the 10-tab Ophthalmology template set.

1 Ophthalmology ROS pop-up - This pop-up is a one page specialty-specific ROS template that is launched by clicking on the Add button. This template allows you to document ROS information in detail for systems of interest to Ophthalmology. All systems are listed on one template. For each system on the template, indicate that the system is normal by clicking on the All

Negative check box to indicate that all findings for the signs and symptoms listed are negative. (In general, this is only used by practices that have pre-printed forms with Review of Systems questions.)

To document abnormal findings, click on the positive radio button for the appropriate signs or symptoms listed for a system.



Other associated symptoms and pertinent negatives can be documented by clicking in the Other positives and Other negatives fields and selecting from picklists.

Clicking on the system active text will launch the detailed System ROS linked template set, opened to the system ROS pop-up template that was clicked.

Most practices choose to set up a quick-save Review of Systems list of questions that all patients will be asked. Additional questions can always be asked of an individual patient.

2 ROS Defaults –ROS defaults can be selected from the CC_HPI_ROS – OPH template in the ROS section or from the Ophthalmology ROS template. Click in the ROS Defaults field and select the set of defaults to use. ROS findings in the

default set will automatically populate the template. The system is shipped with Globally Normal Adult, Globally Normal Peds, and Globally

Normal Ophthalmology. The defaults can be edited by the practice. The Ophthalmology ROS pop-up template and the detailed systems pop-up templates also

allow users to create and use Quick Save defaults. 3 The “All systems normal” and “All others negative” check boxes -

All systems normal check box – Select this check box to quickly document that all systems are normal. This is the equivalent of selecting the ROS Default "Globally Normal Ophthalmology".

All others negative check box – When you have documented a number of abnormal findings, you can click on this check box to document that all of the remaining systems not yet documented are negative.



ROS will be displayed in the data grid n concatenated format when you have finished your documentation.



Generate Progress Note The Ophthalmology Chart Note document can be generated from several different locations:



Left Navigation Pane - Click the Preview button at the bottom of the sliding left navigation pane.

CC-HPI-ROS tab template - Click the Progress Note button in the bottom right corner of the CC-HPI-ROS tab template.

Provider Start tab template - Click the Progress Note button found in the bottom right corner of the Provider Start tab template.

Plan template - Click the Chart Note active text link in the upper right corner

Coding template - If set up by the practice, the Ophthalmology Chart Note can be generated off-line automatically upon submitting a code for the visit.

Note: The Ophthalmology Chart Note is usually generated at the end of the visit.

Tech Signoff - CC-HPI-ROS Tech Signoff – If sign-off is configured, click the Tech Signoff check box to select

Selecting the Tech Signoff check box will complete documentation on this template. The red round alert icon on the tab will change to a green check mark. The name of the technician logged in and a date and time stamp will be displayed in the read-only Tech Signoff fields.



Reference: Technician and Provider Signoff must be configured on the Ngkbm_Eyeconfig practice template. This has been covered previously in Chapter 3 of this document.

Retina Ophthalmology History The History – OPH tab template (eyeMasterhx) is where patient history can be documented and/or reviewed. Once the patient’s history has been documented for the first time, it will only have to be reviewed and updated with changes and new information during each subsequent encounter.

The following information can be found on the Ophthalmology History template:



History recorded by – will automatically display the user currently logged in the system

Comments

Chart update – allows user to document if data entry is being as part of chart abstraction rather than a visit

Update notes – comments field for Chart update

Glasses wearer check boxes – No or Yes; will display previously documented response

Ocular Medications – data grid displaying list of ocular medications, can select to see active or inactive and patient status

Allergies – data grid displaying list of active allergies

Systemic Medications – data grid displaying list of systemic medications; series of check boxes to document that patient is taking unknown medications: cardiac, high blood pressure, diabetic meds, cholesterol meds, and other unknown meds. (These check boxes for unknown medications should only be used as a place-holder while trying to verify the actual medications that the patient is taking.)

Ocular History – data grid displaying list of past ocular history; indicator to document that patient has prosthetic eye

Systemic History – data grid displaying past medical, surgical and interim history

Family History – data grid displaying family medical history

Social History – data grid displaying history of tobacco use , display of current smoking status/tobacco use, drug use/abuse, alcohol, and caffeine

Blood Sugar – data grid displaying history of reported blood sugar and Hemoglobin A1C results (usually patient-reported)



Medications In Ophthalmology, medications are grouped into two categories and displayed in different data grids, ocular and systemic medications.



Ocular Medications

The Ocular Medications section displays a list of ocular medications documented in the Medication Module for the patient.

Ocular medications will be displayed in a data grid.

Existing ocular medication information can be viewed in detail by double-clicking on a row in the grid with data to open the Ophthalmic Medications pop-up template (oph_ophthalmic_meds).

Medications are filtered so that the grid displays only ophthalmic medications. Click the “Active” or “Inactive” radio button to display current active or inactive medications in the grid. (Found above the grid.)

If a patient is not currently taking any ocular medications, click the “No active ocular meds” check box to select. (Found above the grid on the right.)

New medications can be documented and information for existing medications can be updated through the Medications Module by clicking the Add button found below the grid on the right.

The NextGen Ambulatory EHR is shipped with a list of medications that are configured to be ocular medications. This information can be edited (if, for example, a new medication is now available) on the Ngkbm_Medication_Classes practice template. Alternatively, linking any medication in the Medication Module with an Ocular diagnosis will cause that medication to display in the Ocular Medications grid.

A medication review/reconciliation can be performed by clicking the Reconcile button to launch the Medication Review/Reconciliation pop-up template (medication_review). This is where details for patient adherence can be documented. A medication review is usually performed when there is a transition of care into the practice or from a nursing home stay/hospitalization back into the practice.

After medications have been reconciled, the “Medications reconciled” check box will appear checked. (Found above the grid.)

Patient status can be indicated by clicking on the check box(es) for “Transitioning into care” and/or “Summary of care received”. (Found above the grid.)



Systemic Medications

The Systemic Medications section displays a list of systemic medications documented in the Medication Module for the patient.

Systemic medications will be displayed in a data grid filtered to display only systemic medications.

Existing systemic medication information can be viewed in detail by double-clicking on a row in the grid with data to open the Ophthalmology Medications pop-up template (oph_nonophthalmic_meds). Alternatively, the Medication Module may be opened to easily view details on several medications at one time.

If a patient is not currently taking any medications, select the “No systemic meds at this time” check box. (Found above the grid on the right.)

New medications can be documented and information for existing medications can be updated through the Medications Module by clicking the Add button found below the grid on the right. (Note: The Add button below the Ocular Medications grid and the Add button below the Systemic Medications grid both open the Medication Module.)

A medication review/reconciliation can be performed by clicking the Reconcile button above the Systemic Medications grid to launch the Medication Review/Reconciliation pop-up template (medication_review). This is where details for patient adherence can be documented. A medication review is usually performed when there is a transition of care.

After medications have been reconciled, the “Medications reconciled” check box will appear checked. (Found above the Ocular Medications grid.)

Patient status can be indicated by clicking on the check box(es) for “Transitioning into care” and/or “Summary of care received” . (Found above the Ocular Medications grid.)

Unknown Medications

The Systemic Medications section also includes a list of check boxes used to document that the patient is taking different types of unidentified medications to address a medical condition.



Patient is taking unknown cardiac meds.

Patient is taking unknown high blood pressure meds.

Patient is taking unknown diabetic meds.

Patient is taking unknown cholesterol meds.

Patient is taking unknown meds: (Click in the field and manually type in the description using free text.)

Note: Refreshing Data Grids to Display Updated Information from the Medication Module If you document medication information in the Medication Module, you will not see the new information until the Medications data grid has been refreshed. The Medications data grids can be refreshed quickly by navigating away from the History template and returning to it. You can also click the Refresh button found below the grid. Refreshing the grid is a limitation of current technology, and occurs when you go to another module to document information. The corresponding data grid must be refreshed in order to display the updated information. Refreshing the data grid(s) occurs when you close and open the template, or navigate away from it and return.



Documenting Medications in the Medications Module The Medications module is launched by clicking the Add button found below the Medications grid. New medications can be documented for the patient, and details for existing medications can be updated.

Documenting Medications for the Patient:

1 Click the Add button below the Medications grid to launch the Medications module.

2 Click the Prescribe New button in the middle toolbar of the Medications module main screen to open the Medication Search window. (Note: The Prescribe New button is used even when merely entering prescriptions that others have prescribed. If others have prescribed medications, these medications will be 'prescribed' but not dispensed.)

3 Select the medication using the Medication Search window.

a) If you are not sure what filters are selected, click the Filter button to open the drop-down list.

b) If not already selected (have check marks), select the appropriate filters by clicking on filter(s) you wish to use.

c) In the Find field in the upper left, type in the first few letters of the medication name.

d) If the list isn’t updated automatically, click the Search button.

e) Double-click on the mediation in the displayed list to select. The medication will be listed in the Selected Medications section at the bottom of the Medication Search window.

f) If a medication is already on a provider’s Favorite list, it will be seen on the right side of the panel in the ‘All’ tab. The medication can be selected from the Favorite list by double-clicking on it.



g) Highlight the medication in the Selected Medications section and click the Select button. The Medication Search window will close, and the medication will be displayed in the module’s main screen.

4 On the main screen, default information for the medication will be displayed. (This can be modified if necessary.):



Sig – will display the standard prescribed sig for the medication. This can be modified if necessary.

Units – will display the unit that corresponds to the formulation in which the medication is most frequently dispensed. This can be modified if necessary.

Start date – by default is the current encounter date Provider – by default is the current provider Location – by default is the current location

5 The following are required and must be documented: Quantity Refills

6 Select or document any of the following if appropriate: Dispense as written Prescribed elsewhere – selected if the medication is prescribed by a provider at another clinic

or practice; when selected, the Sig, Quantity, and Refills are not required PRN – selected if the medication is to be taken as needed Reason – used to document a reason for taking a medication that is to be taken as needed Problem – used to associate a medication to one of the patient’s active problems (diagnoses) Note – used to add a free text medication note, which can be seen on the Medications module

left pane when the Rx Note tab is selected but will not display on the prescription itself 7 After entering information for the medication, click Accept. (Acknowledge any warnings if they

appear.)

8 After documenting all medications, exit using the “X” in the upper right corner of the Medications module.



The Medication Review pop-up template is launched from the Medications panel on the Ophthalmology Home Page template by clicking the Reconcile button. This is where a review or reconciliation of the patient's medication can be performed manually or electronically.

Reference: Refer to NextGen KBM documentation for Medication Reconciliation and Review for detailed information about this feature.

Medication Reconciliation for a Patient The Medication Review pop-up template (medication_review) is launched from the History tab template by clicking the Reconcile button.



A medication reconciliation is a review of patient adherence as reported by the patient or someone who is acting as the historian for the patient, such as a caregiver.

A medication review is usually performed when there is a transition of care into the practice, or after a hospitalization or nursing home stay.

A medication reconciliation can be performed manually or electronically. A manual medication review/reconciliation is performed on this template.

When first opened, the Medication Module panel will be closed. Expanding this panel will allow

you to see what medications are currently active and documented in the Medication module, including Sig and the last date the medication was refilled.

The Medication Review panel is where medication reconciliation is performed.

There are two data grids on the Medication Review panel.

a) Medication List grid (upper) - displays a list of medications that are active in the Medication module. These are the medications to be reviewed for patient adherence.

b) Medication Review grid (lower) - will display medications that have been reviewed



To review medications manually:

1 Click the Review – adherence check box found above the Medication List grid.

2 Click in the field to the right of the Review – adherence check box and select a patient adherence comment from the picklist. By default, “taken as directed” will populate the field automatically. To enter a comment not found in the picklist, select the top blank line and manually type in

your comment in the field. 3 To document adherence for medications one at a time, click on one row in the Medications List at

a time. This will allow you to select different comments for different medications.

- or -

You can document adherence for all of the medications in the Medication List grid at one time by clicking on the “Review All – Taken As directed” button found above the Medication Review grid on the right.

4 Clicking on a row in the Medications List grid or the “Review All – Taken As directed” button will move the medication(s) to the lower Medication Review grid with the same adherence.

5 If you decide to change the adherence for a medication after you have reviewed it, you can select the row in the Medication Review grid and use the fields below the grid to update the adherence. Click on the row in the Medication Review grid to select it and its details will be displayed in

the fields below the Medication Review grid. The medication and its Sig information can only be edited from the Medications module so

this information will appear disabled. Adherence can be changed by clicking in the field and selecting from the picklist.



Click Update to complete the change and have it display in the Medications Review grid. Click Remove to remove a highlighted medication from the Medication Review grid and move

it back up to the Medications List so that it will have the state of not having been reviewed.

6 For a manual reconciliation, at the top of the template in the Reconciliation Type panel, click the check box to indicate that the “Manual reconciliation was completed”.

7 After completing the medication review, click the appropriate check box(s) to document Patient Status at the bottom of the Medication Review template: Transitioning into care Summary of care received

8 Click Save & Close to exit the Medication Review pop-up template.



9 If not previously done, click the “Medications reconciled” check box found above the Medications grid on the right when you have completed the reconciliation.

Reference: Refer to NextGen KBM documentation for Medication Reconciliation and Review for detailed information about this feature.

Allergies The Allergies section displays a list of allergies documented in the system for the patient.



New Allergies can also be documented and existing allergies updated using the Allergies module by double-clicking on any line in the Allergies grid.

If a patient currently does not have any known allergies, select the “No allergies” check box. (Found above the grid on the right.)

Indicate that allergies have been reviewed by selecting the appropriate option above the grid: “Allergies added today” or “Reviewed, no change”.

Note: If the Joint Commission Standards (formerly known as JCAHO) have been enabled on the ngkbm_config practice template, allergy information will always have to be documented first, from Home or Intake template, immediately after selecting patient type, specialty, visit type, and historian. After documenting allergies, you can continue to document the encounter, beginning with reason(s) for visit and HPI. For Ophthalmology and the 10-tab template workflow, allergy information will have to be documented first when you open the History tab template.

The Allergies section on the Ophthalmology History tab template is seen below.



The Allergies module is launched by double-clicking on any line, whether empty or not, in the Allergies grid. New allergies can be documented for the patient, and details for existing allergies can be updated.

To document allergies using the Allergies Module:

1 Click the Search button to the right of the Allergy field (the magnifying glass icon) to launch the NextGen - Allergy Selection dialog box.

a) Select the filter option. If you are not sure of the name or spelling of an allergen, select “Contains”. Select one of the other filters if you know.

b) In the Description field, type in the first few letters of the allergen. A list of allergens will be displayed on the pop-up template, corresponding to the filter selected and the letters entered in the Description field.

c) Double-click on the allergen to select it, or click on it and click OK. Click Cancel to exit the template without a selection.

2 The Allergen Type will be populated based on the allergen selected on the Allergy Selection dialog box.

3 If the patient is intolerant to the allergen, click on the Intolerance check box.

4 Select the severity by clicking in the Severity field and selecting from the picklist. Choices include: fatal, mild, mild to moderate, moderate, moderate to severe, and severe.



5 Document the reaction to the allergen by clicking in the Reaction field or on the down-arrow to the right of the field, and select from the drop-down list. If the reaction is not listed, simply type in the reaction manually.

6 Click the Add button to add the allergy, and it will be display in the grid in the upper section of the Allergy module and in the Allergy data grid found on templates.

Note: Allergies that are entered in error can be deleted the same day, if the user has privileges to do so. Allergies that were mistakenly entered in a past encounter that is now locked, have to be ‘resolved’.

Ocular History The Ocular History section displays a history of previously documented ocular conditions and procedures/treatments for the patient.

Above the grid on the left, there is a check box to indicate that the patient has “No past ocular history noted”.

Above the grid on the right are check boxes to indicate that the patient has a prosthetic eye and whether it is the left or right eye.

New information for ocular history can be documented using the Ocular History – OPH pop-up template (mngOcularHistory) launched by clicking the Add button found below the grid on the right.

Clicking on a row in the grid displaying previously documented information will highlight the row and enable the Edit and Remove buttons.

Existing information displayed in the grid can be updated by highlighting the row in the grid and clicking the Edit button. The Ocular History – OPH pop-up template will be opened and will display the details contained in the row.

To remove previously documented information displayed in the grid, click on the row to highlight it and then click the Remove button. - or - An alternative way is to delete the information when it is displayed on the Ocular History – OPH pop-up template by clicking the Delete button found on the toolbar at the bottom of the template. (You will have to open the pop-up template and display the information first.)

The Procedures button found below the grid will open the Record Patient Procedure - OPH template (eyerecordprocedure) which is used to document the details for procedures performed and display a historical record of procedures for the patient in a data grid. This is an optional feature.



Documenting Ocular History In the Ocular History section, click the Add button below the data grid to open the Ocular History – OPH pop-up template (mngOcularHistory).

1 In the top half of the pop-up template, select the radio button for the Category of ocular conditions: Cataract Cornea/Conjunctiva Glaucoma Kerato-refractive Neuro/oph Oculoplastic Retina/vitreous Strabismus

Selecting the category will determine the specific picklists of choices for disease and procedure/management that open.

2 Using the fields in the lower half of the template, select or enter the following details, as needed (Dates are entered using a Calendar and other details are selected from picklists.): Disease Eye Year Procedure Eye Date Global end date – this refers to the global time period for post-operative days included as part

of the billing for the procedure Surgeon Location Outcome

a) The disease and/or procedure/management can be selected from their respective picklists, or the blank line selected and an entry can be typed using free-text.

b) If a selection is made, clicking in the same box again will re-open the picklist. However, closing the picklist will allow a free-text typed addition to the previously-entered entry. The arrow key on the computer keyboard can be used to move the cursor to the correct spot if needed.

3 Click the Save toolbar button at the bottom of the template.

4 To document another condition and treatment, click the “Clear for Add” toolbar button, and repeat steps 1 through 4.

5 If you wish to delete previously saved information, click the Delete toolbar button when the template is displaying the details.

6 When you have completed entering new information, click Save, then Close.

7 Information documented for past ocular history will be displayed in the grid on the panel.



The Ocular History - OPH pop-up template (mngOcularHistory) is shown below.

Documenting Ocular Procedures The Record Patient Procedure – OPH pop-up template (eyerecordprocedure) template was designed to be able to enter procedure information to both the Procedures Module and the Histories table in one place during chart abstraction. It is not commonly used. This template might be used to document procedures recently done by the current provider. It allows for more details to be entered and can be used for billing, if desired. It is sometimes used to be able to enter a higher level of detail than through Ocular history.

1 In the Ocular History section, click the Procedures button below the data grid to open the Record Patient Procedure – OPH pop-up template (eyerecordprocedure).

2 Select the Eye the procedure was performed on: OD, OS or OU. (Found at the top of the template.)

3 The following information about the procedure will be automatically populated: Date of service – will display the current encounter date Procedure provider – will display the currently selected or logged in provider (See top

toolbar.) Procedure location – will display the currently selected location (See top toolbar.)

4 Diagnosis description - Click in the Dx description field to open the Diagnosis Search dialog box. Search for and select the diagnosis, and the description and code will populate the template.

5 Status - Click in the Status field and select the status.

6 Procedure description - Click in the Px description field to open the Procedure Search dialog box. After the diagnosis is entered, the Procedure Search dialog box will open automatically. Search for and select the procedure, and the description and code will populate the template.

7 Modifiers - Select up to four billing modifiers using the Modifier fields 1 through 4. If this procedure will not be billed, this step is optional.

8 Select the radio button for the Category of ocular conditions (listed here in alphabetical order): Cataract Cornea/Conjunctiva



Glaucoma Kerato-refractive Neuro Oculoplastic Retina/vitreous Strabismus

9 If the procedure is not to be billed, select the “Suppress billing” check box. This will set up a flag to NextGen® Practice Management that the procedure is not to be billed.

10 To add the procedure to the Histories Master, select the “Add to histories master” check box.

11 Click the Add button at the lower right of the Procedures Details section of the template to add the procedure to the Procedures data grid and to the Histories Master data grid.

12 Click the Return button to close this template and go back to the History tab template (eyeMasterHx).

The Record Patient Procedure - OPH template (eyerecordprocedure) is seen below.

Systemic History The Systemic History section displays a history of previously documented medical, surgical, and interim history for the patient.



Above the grid on the left, there is a check box to indicate that the patient has “No pertinent medical history”.

Above the grid, a “Detailed” check box can be selected so that the detailed past medical/surgical/interim history is included in the generated document. This is commonly selected for a new patient.

Above the grid on the right, a “Reviewed, no changes” check box can be selected to indicate that the patient’s past medical/surgical/interim history has been reviewed and there were no changes.

Above the grid on the right, a “Reviewed, updated” check box can be selected to indicate that the patient’s past medical/surgical/interim history has been reviewed and updated with new information.

New information for medical and surgical history can be documented using the Past Medical History popup template (frw_pastmedsurg_hx) launched by clicking the Add button found below the grid on the right. (This is covered in detail in the next section.)

Clicking on a row in the grid displaying previously documented information will highlight the row and cause the Edit and Remove buttons to be enabled.

Existing information displayed in the grid can be updated by highlighting the row in the grid and clicking the Edit button. The Past Medical History pop-up template will be opened and will display the details contained in the row. Make any changes and click Save & Close.

To remove previously documented information displayed in the grid, click on the row to highlight it and then click the Remove button.

The Systemic History section of the History - OPH tab template is seen below.

Past Medical and Surgical History Past medical and surgical history is documented using the Past Medical History pop-up template (frw_pastmedsurg_hx), launched from the Systemic History section found on the History tab template (eyeMasterHx) by clicking the Add button found below the grid on the right. The new Past Medical History pop-up template is a multi-specialty template that is part of the Core functionality.

When the Past Medical History pop-up template is first opened, the currently selected specialty will be displayed in the Specialty field at the top left of the template. The Medical panel on the template will be expanded, and the Surgical panel will be collapsed. At the bottom, the Past Medical History Grid panel will be expanded to display all currently documented past medical and surgical history for the patient. At the very bottom of the template, you will find the Save & Close and the Cancel buttons. When all panels are expanded, you will have to use the right side scroll bar to get to view the grid and to get to the buttons to exit the template. To easily get to the Save & Close and Cancel buttons, you can collapse all panels.



General Workflow for Documenting Past Medical and Surgical History

1 Click the Add button found in the Systemic History section of the History tab template to launch the Past Medical History pop-up template.

2 Document past medical history on the Medical panel. Click Save to Grid.

3 Document past surgical history on the Surgical panel. Click Save to Grid.

4 After you have completed documenting past medical and surgical information for the patient, click the Save & Close button found at the bottom of the template.

Documenting Past Medical History Past medical history is documented on the Medical panel of the Past Medical History pop-up template.

1 If not already expanded, expand the Medical panel on the Past Medical History pop-up template.

2 Click on the appropriate check boxes to select medical history.

3 Conditions listed in black font represent a single general disease/disorder. For those items listed in black font, clicking on the check box to select the disease/disorder

will cause a date field to appear for Onset and a Manage active text link. Click in the Onset field that appears, and enter a date using the Date Selection dialog box. An

exact date does not need to be entered. Just the year can be entered if desired.



Click the Manage active text link to open the Manage Past Medical History pop-up template to document details for the disease/disorder and its past treatment and management. The Disease/Disorder field will appear disabled and will display your selected disease or disorder.

Documentation will begin on the upper left in the Disease/Disorder section. An onset date can be entered, if not previously done. The side can be indicated.

On the upper right side, Management information can be entered as needed. Below the Disease/Disorder section, there are fields to document Outcome and to type free-

text Comments. Comments that are entered will have the initials of the person entering the comment and the date entered just before the comment.

Note: The Onset field and the Manage link are not required fields. Sometimes the patient is not able to give very specific information about their medical history.

4 Conditions listed in blue font represent a category of diseases/disorders with more than one diseases or disorders associated with it. Conditions listed in blue font behave as an active text link and will launch the detailed Manage

Past Medical History pop-up template with the disease/disorder selection dbpicklist opened. The user can then immediately select a more defined condition and document details for the disease/disorder and for its treatment and management.



5 After you have completed making your selections and documenting any details for them, click the “Save to Grid” button to save this information and upload it to the History grid. (If you launched the Manage Past Medical History pop-up template to document details and saved to the grid there, you do not have to perform this step.)

Documenting Past Surgical History Past surgical history is documented on the Surgical panel of the Past Medical History pop-up template.

1 If not already expanded, expand the Surgical panel on the Past Medical History pop-up template.

2 Click the appropriate check boxes to select surgical history.

3 Surgical procedures listed in black font represent a single procedure. For those items listed in black font, clicking on the check box to select the surgery will cause a

Date field and a Manage active text link. Click in the Date field that appears, and enter a date using the Date Selection dialog box. An

exact date does not need to be entered. Click on the Manage active text link to open the Manage Past Medical History pop-up

template to document details for the surgery in the Management section of the template.



The Management field will display your selected surgical procedure, and you can add any additional details including outcome and comments. (This is covered in detail for in the section discussing how to use the Manage Past Medical History pop-up template.)

4 Surgical procedures listed in blue font represent a category of surgical procedures with more than one procedure or location associated with it. Surgical procedures listed in blue font behave as an active text link and will first open a

dbpicklist of more specific procedures for the selected category, and after selecting from the dbpicklist, will launch the detailed Manage Past Medical History pop-up template.

The Management field will display your selected surgical procedure, and you can add any additional details including outcome and comments. (This is covered in detail in the section discussing how to use the Manage Past Medical History pop-up template.)



5 After you have completed making your selections and documenting any details for them, click the “Save to Grid” button to save this information and upload it to the History grid. (If you launched the Manage Past Medical History pop-up template to document details and saved to the grid there, you do not have to perform this step.)

6 Click Save & Close when done.

Documenting the Management of Past Medical History Note: If you have previously selected a disease/disorder or surgical procedure on the main Past Medical History pop-up template, the Disease/Disorder or the Management field will already display your selection, and its associated SNOMED code will already be populated.

1 Document details in the Disease/Disorder section by clicking in fields and selecting from picklists or Calendars.

a) Select the disease or disorder from the dbpicklist and it will populate the Disease/Disorder field. Its corresponding SNOMED code will automatically populate the SNOMED code field.



b) Enter Onset date.

Click in the field and use the Date Selection dialog to enter a date.

c) If appropriate, select Side by clicking in the field and selecting from the picklist.

2 Document details in the Management section.

a) Enter Management by clicking in the field and selecting from the picklist, and then click Save & Close. (If you are coming to this pop-up template after selecting surgery from the Surgical panel, it will be displayed automatically.)

The method of managing the disease/disorder will be displayed in the Management field, and its corresponding SNOMED code will automatically populate the SNOMED code field.



Interim History Interim history refers to all of the medical encounters a patient has had since their last visit to the practice, such as any hospitalizations, emergency room, office visits and same day surgeries. The Interim History [New Record] pop-up template (histories_interim) is launched from the Systemic History section found on the History tab template by clicking the Interim History button found below the grid on the right.

To Document Interim History

1 In the Systemic History section, click the Interim History button.

2 Click in the Encounter type field and select from the picklist. Emergency room Hospitalization Office visit Same day surgery

3 Problem - Click in the Problem field and manually type in the problem that was addressed during the encounter using free text.

4 Date – Click in the Date field and select a date from the Calendar pop-up.

5 Provider – Click in the Provider field and select from the dbpicklist. Or, close the picklist and type in a name using free text.

6 Hospital – If appropriate, click in the Hospital field and select from the picklist. To enter a hospital not listed, select the top blank line and manually type using free text.

7 Admit Date – If appropriate, click in the Admit date field and select a date from the Calendar pop-up.

8 Discharge Date – If appropriate, click in the D/C date field and select a date from the Calendar pop-up.

9 Outcome/Detail – If appropriate, click in the Outcome/detail field and select from the picklist. To select an outcome that is not listed, select the top blank line and manually type in using free text.

10 Comments – If appropriate, click in the Comments field and manually enter any additional details using free text.

11 Click the Save toolbar button found at the bottom of the pop-up template.

12 To document another interim history encounter, click the “Clear For Add” toolbar button.



13 When you have completed documenting interim history, click the Close toolbar button to exit the pop-up template and return to your workflow on the Histories tab template.

After closing the Interim History pop-up template, documented events will be displayed in the Past Medical/Surgical/Interim History grid on the History tab template.

Family History The Family History section displays a history of previously documented family history for the patient.



Above the grid on the left, there are two check boxes to indicate that the patient has “No relevant past family history” or that the patient is adopted, “Adopted – no family history known”.

Above the grid on the right, a “Detailed” check box can be selected so that the detailed family history is included in the generated document. This is commonly used on new patients.

Above the grid, a “Reviewed, no changes” radio button can be selected to indicate that the patient’s family history has been reviewed and there were no changes.

Above the grid on the right, a “Reviewed, updated” radio button can be selected to indicate that the patient’s family history has been reviewed and updated with new information.

Above the grid on the left, an “Unobtainable” radio button can be selected to indicate that the patient’s family history cannot be obtained.

Previously documented information will be displayed in the grid. Clicking on a row in the grid will highlight the row and enable cause the Edit and Remove buttons to be enabled.

Existing information displayed in the grid can be updated by highlighting the row in the grid and clicking the Edit button. The Family History Details pop-up template (Family_Hx_Dtl) will be open and will display the details contained in the row.

To remove previously documented information displayed in the grid, click on the row to highlight it and then click the Remove button.

Documenting Family Health History The Family Health History template (frw_family_hx) is launched from the Family History section found on the History tab template by clicking the Add button found below the grid on the right. The new Family Health History pop-up template is a multi-specialty template that is part of the Core template functionality.



There are no panels on this template.

At the very top of the pop-up, click in the Specialty field and select your specialty from the dbpicklist, if it is not already selected.

At the top of the template, you can document that there is no family history of a disease or disorder by clicking the “No family history of” check box. This check box can be selected before you select diseases and disorders from the list of conditions found on the template. Multiple diseases can be selected prior to clicking the Save to Grid button.

To document history for family members, click in the Relationship field found in the upper left of the template to select a family member. You can manually type in the name of the family member in the "Family member name" field and indicate if the member is "Alive and well" or "Deceased".

You can document positive family history without specifying a family member.

The middle of the template displays a list of diseases and disorders that can be selected by clicking on the corresponding check box.

Below the check list of diseases/disorders, the Family Health History grid will display all currently documented family history for the patient.

At the very bottom of the template, you will find the Save & Close and the Cancel buttons.



Documenting on the Family Health History Template When documenting family history on the Family Health History template (frw_family_hx), you can document diseases and disorders that family members have been diagnosed with, along with age of onset and whether the diagnosis was the cause of death, or you can document that there is no family history of a disease or disorder.

Documenting Family History of a Disease or Diagnosis

1 At the very top of the template, if not already selected, click in the Specialty field and select your specialty from the dbpicklist.

2 Enter details for the family member being documented

a) Relationship - At the top of the pop-up template, click in the Relationship field and select the family relation from the picklist.

b) Family member name – If needed, document the family member’s name by clicking in the field and manually typing using free text.

c) Select status of the family member, if indicated, by clicking the appropriate radio button, if indicated:

“Alive and well” - This should be selected for a family member who is alive and does not have a medical condition. (To avoid confusion, note that if the person is alive but has a serious illness or condition, that person is alive but not considered well.)

“Deceased” – selecting will cause the “Age at death” field to appear, where age can be entered by clicking in the field and using the on-screen numeric keypad to enter a number for age.

3 Click the appropriate check boxes to select family history diseases or disorders.

a) Conditions listed in black font represent a single general disease/disorder.

For those items listed in black font, selecting the check box for the disease/disorder will cause the corresponding Onset age field to be enabled with a check box to indicate that this was “Cause of death” and a Comments active text link to appear.

Both the Onset age and Deceased age can be clearly entered.

Click in the enabled Onset age field, and enter an age using the on-screen numeric keypad.

If the disease/disorder was the cause of death, select the check box for “Cause of death”.

Enter any comments by clicking the Comments active text link to open the Family History Comments pop-up template. Comments can be entered manually by typing in free text or by making selections using My Phrases. Click Save & Close to save comments and close the template, or click Cancel to close the template without saving.

Note: On the Family Health History pop-up template, clicking the Clear button will clear out all selections made that have not yet been saved to the grid. This will allow you to clear your selections and start over without exiting the template.



b) Conditions listed in blue font represent a category of diseases/disorders with more than one

defined condition associated with it and/or more than one family relationship description associated, from which multiple items can be selected as needed.

For example, a family member may have elevated lipids with both high cholesterol and hyperlipidemia, and that family member may be a first degree relative for the patient. In this example, the Elevated lipids link will allow the selection of various types of elevated lipids and whether a first degree relative had high cholesterol.

Conditions listed in blue font behave as an active text link and will launch the detailed Family History Expanded Conditions pop-up template (frw_hx_secondary), where documentation for the condition will continue.

On the Family History Expanded Conditions pop-up template, click in the first available field and select the disease/disorder. Some diseases in the list also include whether this condition is present in a first degree relative.

Note: Entering family history on first degree relatives is a Meaningful Use Stage 2 measure.

Click in the enabled Onset age field, and enter an age using the on-screen numeric keypad.

If the disease/disorder was the cause of death, select the check box for “Cause of death”.



Enter any comments by clicking the Comments active text link to open the Family History Comments pop-up template. Comments can be entered manually by typing in free text or by making selections using My Phrases. Click Save & Close to save comments and close the comments pop-up template, or click Cancel to close without saving.

After you have completed entering details for the disease/disorder on the Family History Expanded Conditions pop-up template, click "Save to Grid & Close" to return to the Family Health History pop-up template, or click Cancel to close without saving.



4 On the Family Health History pop-up template, if not already done, click the “Save to Grid & Close” button to upload the documented information to the Family Health History Grid on the Family Health History template. (Note that information that was documented on the Family History Expanded Conditions pop-up template will have been uploaded to the grid when exiting the template.)

5 Repeat Steps 1 through 3 to document health history for each family member.

6 When you have completed documenting family health history, click Save & Close to save information and exit the Family Health History template, or to exit the Family Health History template without saving, click Cancel.

Documenting No Family History of a Disease or Disorder

1 At the very top of the template, if not already selected, click in the Specialty field and select your specialty from the dbpicklist.

2 Select the “No family History of:” check box found in the top left corner of the Family Health History pop-up template.

The list of diseases and disorders will no longer have visible fields for documenting onset age and indicating cause of death.

3 Select the check box corresponding to each disease or disorder to be selected.



4 Click the Save to Grid button to upload this information to the Family Health History Grid.

5 When you have completed documenting family health history, click the Save & Close button to save information and exit the Family Health History pop-up template, or to exit the Family Health History template without saving, click Cancel.

Social History The Social History section displays a history of previously documented tobacco use history for the patient, along with details for tobacco cessation, use of alcohol, caffeine, and drug use/abuse.



Above the grid on the left, a “Detailed” check box can be selected so that the detailed social history is included in the generated document.

Above the grid, a “Reviewed, no changes” radio button can be selected to indicate that the patient’s social history has been reviewed and there were no changes.

Above the grid on the right, a “Reviewed, updated” radio button can be selected to indicate that the patient’s social history has been reviewed and updated with new information.

Above the grid on the left, an “Unobtainable” radio button can be selected to indicate that the patient’s social history cannot be obtained from the patient or anyone else.

Previously documented information for tobacco use will be displayed in the grid.

Tobacco use is documented on the Social History – Tobacco pop-up template, launched by clicking the Tobacco Use active text. The Social History – Tobacco pop-up template will open with the Tobacco Use, Historical Use, and Efforts to Quit Tobacco panels expanded.

Tobacco Cessation is documented on the Tobacco Cessation template, launched by clicking the Tobacco Cessation active text link. The Tobacco Cessation template can be used when extensive counseling is done. The Tobacco Cessation discussed checkbox can be checked to indicate brief, less than 3 minutes, counseling.

Alcohol – Document alcohol use by selecting the No or Yes or Formerly radio button; If “yes”, document Amount and Frequency by clicking in the fields and selecting from picklists.

Drug use/abuse – Document drug use/abuse by selecting the No or Yes or Formerly radio button; If “yes”, document Type by clicking in the fields and selecting from the picklist.

Caffeine – Document caffeine use by selecting the No or Yes radio button; If “yes”, document Amount per day by clicking in the field and selecting from the picklist.



Blood Sugar The Blood Sugar section displays a history of manually documented results of Glucose and HbA1c testing. Testing levels can be reported by the patient or the physician.

To document Blood Sugar testing:

1 Click the Add button found below the grid on the right to open the Blood Sugar Control – OPH pop-up template.

2 Reported by – Click on the appropriate check box to select “Per Patient” or “Per Provider”.

3 Document Glucose testing

a) Click in Glucose field and enter result using on-screen keypad.

b) Click in Last checked field and enter the date glucose level was last tested.

c) Click in the Time field and enter the time of last test.

4 Document HgA1c testing

a) Click in HgA1C field and enter result using onscreen keypad.

b) Click in Last checked field and enter the date HgA1C level was last tested.

5 Click the Save template toolbar button.

6 To document additional test results, click the “Clear For Add” template toolbar button.



7 Click the Close template toolbar button when you have finished documenting test results.

Generate Note - History Summary Click the Generate Note button found in the bottom right corner of the History – OPH tab template to generate the Ophthalmology History Summary note document if desired. After reviewing the document, click the Close button to close it. If you are using MDI tabs, close the tab displaying the report.



Tech Signoff - History Tech Signoff – If sign-off is configured, click the Tech Signoff check box to select

Selecting the Tech Signoff check box will complete documentation on this template. The red round alert icon on the tab will change to a green check mark. The name of the user logged in and a date and time stamp will be displayed in the read-only Tech Signoff fields.


Ophthalmology Pre-Screening The Pre-Screening template (RECEIVE_DATA) is launched by clicking the Pre-Screening active text in the middle section of the left side navigation pane. This template is designed to retrieve various readings from equipment through implemented interfaces, such as lensometers, autorefractors, keratometers, and phoropters.



After all readings have been captured from the various instruments, continue to the Tech Exam.



Ophthalmology Tech Exam The Tech Exam – OPH tab template (eyeTechExam) is where exams performed by the technician are documented.

Technician performed exams include:

Visual Acuity

Lensometry

Refraction – Autorefraction, Manifest refraction, Cycloplegic refraction

Keratometry – Keratometry, Simulated Ks, Manual Ks

Amsler Grid

Intraocular Pressure (IOP)

External Exam

Most exam findings can be entered by clicking in a field and selecting from a picklist. For refractive exam parameters, the sphere picklists first launch containing all minus values, while the cylinder picklists start with plus values. Selecting the top blank line will cause a second picklist to be launched with the opposite values. Therefore, if the first picklist is the minus values picklist, the second picklist launched will be the plus values picklist, and vice-versa.

After completing documentation of Visual Acuity findings, click the Save button found above the Visual Acuity grid to save and upload the visual acuity findings to the data grid. After documenting Intraocular Pressure findings, click the Save button found above the IOP grid to save and upload the IOP findings to the data grid.

General Workflow for Documenting Tech Exam Findings

1 From the Tech Exam template (eyeTechExam), navigate to the section for the exam to be performed and documented.

2 Document exam findings. For many parameters, findings can be documented by clicking in a field and selecting from

picklists. Visual Acuity and IOP exam sections will have a data grid displaying historical exam

information.



3 For Visual Acuity and IOP exams, click Save to save exam findings and upload them to their grids.



Visual Acuity Exam The Visual Acuity grid can be found on the following templates:

Home – OPH (eyemaster_im) – used for review and entry of historical acuities

Tech Exam – OPH (eyeTechExam) – used for documenting current technician exam findings

Visual Acuity findings are documented using serial picklists, where findings for an exam parameter are entered followed by a modifier for the parameter. Values are entered by picklist selections. Parameters are organized into two rows, one for the right eye (OD) and the other for the left eye (OS), and by Distance Visual Acuity (Dva) and Near Visual Acuity (Nva).

To entering Visual Acuity findings:

1 Enter values by clicking in the field immediately to the right of the OD parameter (such as OD DVA sc) and selecting a value from the picklist that is launched.

2 The second field to the right of the parameter is for modifier values. After selecting a value for OD, click in the Modifier field, if desired, to launch the picklists for Modifiers for OD. These picklists will not be launched automatically. Select a modifier value if needed.

3 Follow by clicking in the field immediately to the right of the OS parameter (OS Dva sc) to document this value and any modifier.

4 Repeat steps 1 – 3 to enter all visual acuity values.

5 Click the Save button to save values to the Visual Acuity exam data grid, and the values displayed in the fields will change to a pink colored font to indicate that the values have been saved.



The following screen capture shows the Visual Acuity exam section of the Tech Exam template showing historical and current visual acuity exam findings. Currently, only exam findings for the current exam exist.

Lensometry and Refraction The Lensometry fields are found below the Visual Acuity grid, and can be found on the following templates:

Tech Exam – OPH (eyeTechExam) – used for documenting technician exam findings The Lensometry and Refraction sections are for documenting glasses prescriptions and refraction:

Lensometry – glasses prescriptions are documented

Autorefraction – results of refraction measured using an Autorefractor are documented

Manifest RX – results of refraction measured while eye is able to accommodate (in its natural state, not dilated) are documented

Cycloplegic – results of refraction measured after the administration of cycloplegic eye drops, which temporarily paralyze the focusing muscles of the eye, are documented

Lensometry and refraction findings are documented using serial picklists that automatically launch in sequence after a value is selected. Values are entered by picklist selections that cause the next picklist to launch automatically. Parameters are organized into two rows, one for the right eye (OD) and the other for the left eye (OS). After clicking in the first parameter field and making a selection from the first picklist, each of the remaining picklists in the series will automatically launch in sequence after you select a value.



Often picklists have all negative values or all positive values. If the first picklist launched does not have the values you want, select the top blank link to automatically launch a second picklist. For example, if the first picklist has all negative values, select the top blank line to launch a second picklist containing all positive values. Enter values using picklists and the onscreen numeric keypad, many of which will launch automatically after clicking in the first field for OD. Repeat the process to enter values for OS.

Documenting Lensometry Findings To enter Lensometry findings:

1 Dominant Eye - Select Dominant Eye if not previously documented. (Previously documented value will be displayed automatically.)

2 Glasses Type – Select Glasses Type if not previously documented. (Previously documented value will be displayed automatically.)

3 SPH - Enter values for OD by clicking in the field for SPH (the first OD parameter) and selecting a value from the picklist that is launched. The first picklist for the first parameter for a section usually has all negative values. Select the top blank line to launch the second picklist containing all positive values if needed. If no value is needed for the parameter, select the top blank line on positive values picklist.

4 CYL - After selecting a value for SPH, the first picklist for OD CYL will be launched automatically. Select a value or select the top blank line to launch the second picklist of values for the

parameter. If no value is needed from the second picklist, select the top blank line again.

5 Axis - After selecting a value for CYL, the onscreen numeric keypad for Axis will be launched automatically. Enter a value using the onscreen numeric keypad or if no value is needed, do not enter

anything. Click OK. (Clicking Cancel will cause you to have to click in the next parameter field in order

to start the sequential picklists again.)



6 ADD - After entering a value for Axis, the picklist for ADD will be launched automatically. Select a value from the picklist or select the top blank line to type in a value using free text.

7 Prism 1 - After selecting a value for ADD, the picklist for Prism 1 will not be launched automatically. This field launches only one picklist. To document, click in the field and select a value from the picklist. The picklist for the next

parameter Base 1 will be launched automatically if a value is selected for Prism 1. 8 Base 1 - After selecting a value for Prism 1, the picklist for Base 1 will be launched automatically.

Select a value from the picklist or select the top blank line to not enter a value. 9 Prism 2 - After selecting a value for Base 1, the picklist for Prism 2 will not be launched

automatically. This field launches only one picklist. To document, click in the field and select a value from the picklist. The picklist for the next


Select a value from the picklist or select the top blank line to not enter a value.

11 Repeat steps 3 – 10 for OS.

Documenting Autorefraction Findings To enter Autorefraction findings:






to start the sequential picklists again.) 4 ADD - After entering a value for Axis, the picklist for ADD will not be launched automatically.

This field launches only one picklist. To document, click in the field and select a value from the picklist or select the top blank line

to type in a value using free text. 5 Dva - After selecting a value for ADD, the picklist for Dva will not be launched automatically.



This field launches only one picklist. To document, click in the field to launch the picklist. Select a value or select the top blank line

to type in a value using free text. 6 Nva - After selecting a value for Dva, the picklist for Nva will not be launched automatically.

This field launches only one picklist. To document, click in the field to launch the picklist. Select a value or select the top blank line

to type in a value using free text. 7 Repeat steps 1 – 6 for OS.

8 Click the Streak check box to select, if applicable.

Documenting Manifest Refraction and Visual Acuity Findings The Manifest RX section is organized in the following way:

Manifest refraction - An upper row is for manifest refraction values, with OD on the left side and OS on the right side

Manifest visual acuities - A lower row is for manifest visual acuity values, with OD on the left side, OS on the right side, and OU below the OD and OS fields

To enter Manifest Refraction and Visual Acuity findings:






to start the sequential picklists again.) 4 ADD - After entering a value for Axis, the picklist for ADD will be launched automatically.

Select a value from the picklist or select the top blank line to type in a value using free text or not enter a value.


parameter Base 1 will be launched automatically if a value is selected for Prism 1.



6 Base 1 - After selecting a value for Prism 1, the picklist for Base 1 will be launched automatically. Select a value from the picklist or select the top blank line to not enter a value.

7 Prism 2 - After selecting a value for Base 1, the picklist for Prism 2 will not be launched automatically. This field launches only one picklist. To document, click in the field and select a value from the picklist. The picklist for the next


Select a value from the picklist or select the top blank line to not enter a value. 9 Dva - The picklist for Dva will not be launched automatically except after a value or the top blank

line has been selected for Base 2. This field launches only one picklist. To document, click in the field if picklist did not launch automatically and select a value from

the picklist or select the top blank line to close the picklist without entering a value. 10 Nva - After selecting a value for Dva, the picklist for Nva will be launched automatically.

This field launches only one picklist. To document, click in the field if picklist did not launch automatically and select a value from

the picklist or select the top blank line to close the picklist without entering a value or to type a value using free text.


12 Document OU manifest visual acuity values (both eyes) Dva - Click in the field if picklist did not launch automatically and select a value from the

picklist or select the top blank line to not enter a value. Nva - Click in the field if picklist did not launch automatically and select a value from the

picklist or select the top blank line to not enter a value or to type a value not listed using free text.

NPA (Near Point Accommodation) - Click in the field if picklist did not launch automatically and select a value from the picklist, or select the top blank line and type a value not listed using free text.

NPC (Near Point Convergence) - Click in the field and select a value from the picklist, or select the top blank line and type a value not listed using free text.

13 Epic Manifest – Click the Epic Manifest check box to select, if appropriate.

14 Comments – Enter any comments by clicking in the Notes field and manually typing free text.

Documenting Cycloplegic Rx and Dva Findings The Cycloplegic RX section is organized in the following way:



The Cycloplegic RX section will not display fields for data until you click the Cycloplegic RX check box.

Cycloplegic refraction - An upper row is for manifest refraction values, with OD on the left side and OS on the right side

Cycloplegic distance visual acuity - A lower row is for cycloplegic visual acuity values for distance (Dva), with OD on the left side, OS on the right side, and OU below the OD field

To enter Cycloplegic Refraction and Dva findings:

1 Click the Cycloplegic RX check box in order to select this exam and to display the fields used to document cycloplegic refraction.





anything. Click OK.

5 ADD - After entering a value for Axis, the picklist for ADD will not be launched automatically. To document, click in the field and select a value from the picklist.



Select a value from the picklist or select the top blank line to not enter a value. 8 Prism 2 - After selecting a value for Base 1, the picklist for Prism 2 will not be launched

automatically. This field launches only one picklist. To document, click in the field and select a value from the picklist. The picklist for the next


Select a value from the picklist or select the top blank line to not enter a value. 10 Dva - The picklist for Dva will not be launched automatically.



This field launches only one picklist. To document, click in the field and select a value from the picklist.


12 Document OU cycloplegic distance visual acuity (Dva) value (both eyes) Dva - Click in the field and select a value from the picklist.

Keratometry Exam The Keratometry fields are found below the Lensometry fields and the Visual Acuity grid. Keratometry fields can be found on the following templates:

Tech Exam – OPH (eyeTechExam) – used for documenting technician exam findings

Keratometry measures the curvature of the cornea. Keratometry exam findings are documented using onscreen numeric keypads that open in a series, starting when you click in the field of the first parameter, and launching automatically for each of the remaining parameters when a value is entered. Parameters are organized into two sections of fields, one for the right eye (OD) and the other for the left eye (OS).

Keratometry fields are always visible. Simulated Ks and Manual Ks fields are not visible until you click on their check box to select the test.

Entering Findings in the Keratometry Section:

1 Enter findings for the right eye (OD)

a) R1 - Click in the field immediately to the right of the R1 parameter and enter a value using the onscreen numeric keypad that is launched.

b) Axis 1 - The second field to the right of the parameter is for the Axis value. After entering a value for R1, enter a value for Axis for R1 using the onscreen numeric keypad that will be launched automatically.

c) R2 - The onscreen numeric keypad will automatically open for the R2 field for that eye. After entering the R2 value, an average of R1 and R2 will automatically display in the Avg field.

d) Axis 2 - After entering a value for R2, enter a value for Axis for R2 using the onscreen numeric keypad that will be launched automatically.

e) CO - Click in the CO size field and enter a value for cornea size by selecting from the picklist of sizes.

f) PU - Click in the PU size field and enter a value for pupil size by selecting from the picklist of sizes.



2 Repeat steps 1a - 1f to enter findings for the left eye (OS).

Entering Findings in the Simulated Ks Section

1 Click on the Simulated Ks check box to select the exam and make the fields visible.


a) R1 - Click in the R1 field and enter a value using the onscreen numeric keypad that is launched.

b) R2 - Click in the R2 field and enter a value using the onscreen numeric keypad that is launched.

c) Axis - Click in the Axis field and enter a value by selecting from the picklist that is launched.

3 Repeat steps 2a– 2c for left eye (OS).

Entering Findings in the Manual Ks Section

1 Click on the Manual Ks check box to select the exam and make the fields visible.


a) R1 - Click in the R1 field and enter a value using the onscreen numeric keypad that is launched.

b) R2 - Click in the R2 field and enter a value using the onscreen numeric keypad that is launched.

c) Axis - Click in the Axis field and enter a value by selecting from the picklist that is launched.

3 Repeat steps 2a– 2c for left eye (OS).

Amsler Grid The Amsler Grid exam section is found on the second page of the Tech Exam template, above the IOP section. The Amsler Grid can also be documented on the Testing tab template.


Testing - OPH – OPH (eyeOtherTests) – used for technician and provider workflow

Documenting Amsler Grid Findings

1 Click the “Draw Amsler Grid” button to display an image of the Amsler grid in the Drawing Module.

2 Select the pencil from the tool bar and draw wavy lines on the grid labeled OD.

3 Click the Save toolbar button, enter a name for the drawing when prompted, and select the format you want to save the image in (bitmap .bmp is default).

4 Click OK, then the Close toolbar button to return to the Tech Exam template.

5 After completing an Amsler Grid drawing, select the Amsler Grid check box and enter descriptive findings, if desired, by clicking in fields and selecting from pick lists.



6 After a finding (or the blank line) is selected from the picklist for the right eye (OD), the picklist for the left eye will automatically open.

IOP Exam The IOP section and grid can be found on the following templates:



Home – OPH (eyemaster_im) – used for technician workflow


Provider Start - used for reviewing information

Posterior Exam template - used for documenting provider findings

Intraocular Pressure (IOP) findings and details are documented using serial picklists to select values. An IOP measurement is documented for each eye, one for the OD eye and the other for the OS eye.

Entering IOP Findings

1 Method - Click in the Method field and select the method used from the picklist. To document a value not included in the list, select the top blank line and manually type using free text.

2 OD - Enter values by clicking in the OD field selecting a value for IOP from the picklist that is launched or select the top blank line if no value is needed. (For example, only the left eye was measured.)

3 OS - After selecting a value for OD, a picklist for OS will be launched automatically. Select a value for IOP or select the top blank line if no value is needed. (For example, only the right eye was measured.)

Note: IOP measurements can be entered in mm Hg and/or Kilopascals.

4 Once an IOP is entered, the name of the logged-on user will automatically populate the “Taken by:” field.

5 Comment - Add comments by clicking in the Comment field and manually typing using free text.

6 If the patient was dilated when the measurements were taken, click the “Dilated” check box to select. If the patient was dilated and this was previously documented, the check box will be selected automatically.

7 Click the Save button to save values to the IOP exam data grid. The IOP measurement values will be displayed in pink font to indicate that they have been saved.

External Exam External eye examination findings are entered in the External Exam section found on the lowermost part of the Tech Exam template.

The short External Exam section can be found on the following templates:




Documenting an External Exam

Copy last exam – Clicking on the “Copy last exam” check box will carry-forward the findings from the last exam. You can then document the changes between the last exam and the current exam.

Default WNL - Click the Default WNL (Within Normal Limits) check box to select. All fields will be automatically populated with normal values for each parameter of the exam. Any area of the exam can be changed as needed.

Enter values by clicking in each field for each parameter, and selecting from the picklist that is launched.

1 Dim mm – Pupil size in millimeters in dim light

2 Bright mm – Pupil size in millimeters in bright light

3 Findings are documented by clicking in the field on the OD side and selecting from picklists. To document a finding not listed, select the top blank line and manually type using free text.

4 Fields are in pairs. The first field is for the Finding. The second field is for the finding’s Modifier.

5 After documenting findings for OD, any findings that are the same for OS can be assigned using the corresponding “>>” buttons.

6 Dilation

a) Click the Add button below the Dilation grid. The Dilation/Other Medications-OPH pop-up template displays.

b) Click in the left Dilated field and a list of dilation drops will open. Select the drops used from the picklist.



c) The picklist to select which eye(s) were dilated will open automatically. Select the eye.

d) The current system time will populate the Time field and the currently logged in user will populate the field next to it.

e) Click the “Patient and/or guardian was advised of all side effects associated with dilation” check box.

f) Click Save & Close to close the pop-up template.

7 If the patient was not dilated

a) Select the “The patient was not dilated” check box on the Dilation/Other Medications pop-up template..

b) Document the reason by clicking in the “Reason patient not dilated” field and select from the picklist. To enter a reason not listed, select the top blank line and type using free text.

c) Document the eye not dilated by clicking in the Eye field and selecting from the picklist.

d) The currently logged in user’s name will populate the field next to it.

8 History recorded by

a) Click on the "History recorded by 1" check box to select. The currently logged in user will be displayed in the read-only field.

b) Add a comment by clicking in the “History recorded by 1 comments” field. A picklist of choices will open. Select from the list or select the top blank line and type a comment using free text. Although the field looks small, it holds 100 characters.

c) To record a second historian, repeat these steps using the “History recorded by 2” fields.



Drawings At the bottom of the Tech Exam tab template is a Draw button. Clicking this button will open a picklist of different drawing backgrounds for Ophthalmology available in the system for use with the Ophthalmology Draw Module. Backgrounds available in the picklist for the Tech Exam template will be different from those available in the examination templates found in the retina provider workflow on the External, Slit Lamp and Posterior Examination templates.



Generate Tech Report Click the Tech Report button found in the bottom right corner of the Tech Exam – OPH tab template to generate the Ophthalmology Tech Report note document if desired. After reviewing the document, click the Close button to close it. If you are using MDI tabs, close the tab displaying the report.

Tech Signoff - Tech Exam Tech Signoff – If sign-off is configured, click the Tech Signoff check box to select

Selecting the Tech Signoff check box will complete documentation on this template. The red round alert icon on the tab will change to a green check mark. The name of the user logged in and a date and time stamp will be displayed in the read-only Tech Signoff fields.


At this point in the encounter, provider workflow begins on the Provider Start tab.



In this section the provider workflow for a patient encounter begins. Provider workflow begins on the Ophthalmology Provider Start - Retina tab template (retptsummary2). Navigate to this template by clicking on the Provider Start tab in the upper row of tabs of the Ophthalmology 10-tab template set or the active text link in the upper section of the left side navigation pane.

Provider Start The Provider Start - Retina template (retptsummary2) provides a summary of all previously documented patient information for physician notes, chief complaints, HPI, plan summaries, post-op exams, vision and intraocular pressure measurements, allergies and PAM/RAM measurements, procedure history, appointment requests and orders, ocular history, diagnostic procedures, labs, medications and past medical history. Its purpose is to review information, rather than add information.

C H A P T E R 7

Provider Workflow

Chapter 7 Provider Workflow


All information is displayed in data grids that can be expanded to see information they contain in detail.

Click the Expand button above the HPI and plan grids on the right side to open a full page template displaying the information found in the grid in a larger format. The provider can review this information before seeing the patient.

On the expanded view template, click the Return button to return to the Provider Start template.

The following data grids are found on the Provider Start – Retina tab template:



Physician Notes

Historic HPI - expanded view available

Note that HPI’s from other specialties can be selected for viewing, if desired, by selecting the ‘All’ radio button on the expanded view.

Plan Summary - expanded view available

Post Op Exams

Vision – graphical representation of historical visual acuity details is available

IOP – graphical representation of historical intraocular pressures details is available

Allergies

PAM/RAM

Procedure History

Appointment Requests/Orders

Ocular History

Diagnostic Office Procedures - expanded view available

Diagnostic Orders External – button to launch diagnostics ordering template which is part of the MyPlan/Orders tabbed template set

Labs – button to launch labs ordering template which is part of the MyPlan/Orders tabbed template set

Ocular Medications – ability to view active and inactive

Systemic Medications

Past Systemic History

Progress note button – found at the bottom right of the template; can be used to generate the Chart Note for the visit

Provider Signoff - Exam If Technician and Provider sign-off has been configured, the sign-off check boxes will serve as a visual cue for the provider and the technician to review each of the main tab templates and to sign-off when this has been completed.



Provider Signoff – If sign-off is configured, click the Provider Signoff check box to select

Selecting the Provider Signoff check box will complete documentation on this template. The red round alert icon on the tab will change to a green check mark. The name of the provider logged in and a date and time stamp will be displayed in the read-only Provider Signoff fields.


Retina Ophthalmology Exam The Exam tab of the 10-tab Ophthalmology template set opens the Ophthalmology Exam tabbed template set used by the Retina sub-specialty, open to the External Exam tab.

The Exam tabbed template set includes:

External Examination (eyeExternalExam)

Slit Lamp Examination (eyeSlitLamp)

Posterior Examination (eyeRetinaExam)

After you have completed documenting exam findings on these examination tab templates, use the sliding left navigation pane to navigate to your next template.

External Exam External Exam findings can be documented on the External Examination tab (EyeExternalExam) of the Exam template set. When you are on the Provider Start tab template using Retina workflow, clicking the Exam tab will open the Exam 3-tab template set opened to the External Examination tab.

If the technician performed an External Exam, those documented findings will be displayed. The provider will then have to review those findings and make any changes or additions that are appropriate.



The following shows the External Examination tab template.

Documenting External Exam

1 In Retina workflow on the Provider Start tab, click on the Exam tab in the upper row of tabs. The 3-tab Exam template set will be launched, open to the External Examination tab.

2 At the top of the External Examination tab, there are fields for PAM and RAM. If these values had been previously entered on the Testing tab, the results would display here. Clicking in each box opens a picklist of choices to select from.

3 Findings for this encounter previously documented by the technician will be displayed.

4 If there is information from a previous encounter, you can copy-forward the last documented exam findings by clicking the “Copy last exam” check box, if you have been given privileges by the practice to do so.

5 If all findings are normal, click the “External WNL” check box for OD and/or OS to populate fields with normal default findings.

6 If there are abnormal findings, click in the fields for the element and select from the picklist.

7 If OS findings are the same as OD findings for an exam element, click the Copy button between the OD field and the OS field to copy the finding from the OD eye to the OS eye.

8 Drawings

a) Click the Draw button to open a picklist of Ophthalmology drawing backgrounds.

b) Select a background from the picklist and the Drawing Module will open with your selected background.

c) After completing your drawings, click the Save toolbar button to name the file and save it.



9 Generate Note - Click the Generate Note button to generate the Ophthalmology Chart Note document, if desired at this point

Note: All versions of the Chart Note that are generated are archived and are discoverable.

10 If you have finished documenting External exam findings, click the Slit Lamp Examination tab to navigate to the next exam. Click the Slit Lamp Examination tab to document the Slit Lamp Exam

- or –

Click on a link in the Expanded Left Navigation panel to navigate to another template.

Slit Lamp Exam The Slit Lamp exam is found on the Slit Lamp Examination tab (eyeSlitlampExam) of the 3-tab Exam template set launched in Retina workflow when you click on the Exam tab.

Documenting Slit Lamp Exam

1 In Retina workflow on the Provider Start tab, click the Exam tab in the upper row of tabs. The 3-tab Exam template set will be launched, open to the External Examination tab.

2 Click the Slit Lamp Examination tab.

3 If there is information from a previous encounter, you can copy-forward the last documented exam findings by clicking on the “Copy last exam” check box, if you have been given privileges by the practice to do so.

4 Alternatively, if all findings are normal, click the “Slit Lamp WNL” check box for OD and/or OS to populate fields with normal default findings.



5 If there are abnormal findings, click in the fields for the element and select from the picklist. Finding Modifier, as needed Some exam elements will have more than one modifier for a finding. To document a finding not listed in the picklist, select the top blank line and manually type in

using free text. 6 If OS findings, with modifier and location, are the same as OD findings for an exam element,

click the Copy button between the OD field and the OS field to copy the finding, its modifier and its location from the OD eye to the OS eye.

7 Document a Gonioscopy exam (optional) Instructions for documenting a Gonioscopy exam can be found in the section that follows. Click the Gonio Exam active text link to open the Gonioscopy - OPH pop-up template, where

you can view or document detailed findings for gonioscopy. After documenting findings, click Save & Close.

The Gonio Exam active text link to the Gonioscopy - OPH pop-up template will turn pink and have a solid wing ding to indicate that the template has information.

8 Drawings

a) Click the Draw button to open a picklist of Ophthalmology drawing backgrounds.



9 Generate Note - Click the Generate Note button to generate a chart note document.

10 If you have finished documenting Slit Lamp exam findings, click the Posterior Examination tab to navigate to the next exam. Click the Posterior Examination tab to document the Posterior Exam

- or –

Click on a link in the Expanded Left Navigation panel to navigate to another template.



Gonioscopy Exam A detailed Gonioscopy exam can be documented from the Slit Lamp Examination tab template by clicking the Gonio Exam active text link found in the Iris section of the template. This detailed exam is optional.

Documenting a Gonioscopy Exam

1 Click the Gonio Exam active text link to open the Gonioscopy - OPH pop-up template, where you can view or document detailed findings for gonioscopy.

2 Up to four text findings can be documented, each with one modifier

3 Document values for Sup, Temp, Nas, and Inf by clicking in the fields and selecting from multi-select picklists. These picklists use the modified Spaeth classification. If the practice uses a different

classification system for Gonioscopy, the picklists can be edited at the practice level. Click Close to exit the picklists.

4 Additional comments can be documented by typing free text in the Comments field.

5 To exit the Gonioscopy pop-up template Click Save & Close to save and return to the OPH – Physical Eye Exam

- or –

Click Cancel to exit without saving.

Note: Making any entry on the Gonioscopy pop-up template will cause 'Gonioscopy' to appear in the list of billable procedures on the Coding tab. However, a diagnosis code will have to be manually added to the Gonioscopy procedure on the Coding tab.



The Gonio Exam active text link to the Gonioscopy - OPH pop-up template will turn pink and have a solid wing ding to indicate that the template has information.

Posterior Exam The Posterior exam is found on the Posterior Examination tab (eyeSlitlampExam) of the 3-tab Exam template set launched in Retina workflow when you click the Exam tab.



The following screen captures show the Posterior Examination tab template. The active text links to detailed exam pop-up templates are pink with a solid wing-ding, indicating that information has been documented on those templates.



In the upper right corner of the Posterior exam tab is the Patient Summary button. This will open a pop-up template showing a summary of visual acuity, IOP, ocular history, ocular and systemic medications, PAM/RAM, diagnostics and labs.



To the left of the Patient Summary button is a ‘Q’ icon. This will open a pop-up template detailing meaningful use quality measures and what information has to be documented for them.

To the left of the Q icon is an Exclusions active text link. If a particular exam required for Meaningful Use is not done (perhaps it was recently done), an exclusion can be entered explaining why the exam was not done.

1 Highlight the measure in the grid, and information populates in the fields above. The item excluded and details can be entered.

2 Item excluded and Exclusion must be selected from the picklist that opens when you click in the respective fields. Exclusion detail can be selected from a picklist or the picklist can be closed and typing free-text in the field. Exclusions for POAG and Diabetic retinopathy are both found on this pop-up template.



3 Click Save & Close when done.

The following detailed examination pop-up templates for Macula can be launched from the Macula section of the Posterior Examination tab:

AMD Detail – Age Related Macular Degeneration

VitreMac Detail – Vitreomacular disorders

Histo Detail – Presumed Ocular Histoplasmosis, also seen as POHS

The following detailed examination pop-up templates for Vessels can be launched from the Vessels section of the Posterior Examination tab:

BDR Detail – Background Diabetic Retinopathy

PDR Detail – Proliferative Diabetic Retinopathy

Vascular Detail – Vascular disorders

Note: Information entered on any of these six pop-up templates will not display on the Exam template but will display in the chart note.



These pop-up templates are optional. Information can be entered using the picklists for each part of the exam, if desired.

Documenting Posterior Exam

1 In Retina workflow on the Provider Start tab, click the Exam tab in the upper row of tabs. The 3-tab Exam template set will be launched, open to the External Examination tab.

2 Click the Posterior Examination tab.

3 If there is information from a previous encounter, you can copy-forward the last documented exam findings by clicking the “Copy last exam” check box.

4 If all findings are normal, click on the “Posterior WNL” check box for OD and/or OS to populate fields with normal default findings.

5 To exclude elements from the exam, click the Exclude link at the top of the Posterior Exam template. Select the pertinent measure and document exclusion details.

6 If there are abnormal findings, click in the fields for the element and select from the picklists. Finding Modifier Location

7 If OS findings, including any modifier and location, are the same as OD findings for an exam element, click the Copy button between the OD field and the OS field to copy the finding, its modifier and its location from the OD eye to the OS eye.

8 Document CD Ratio Either document vertical and/or horizontal cup/disc ratio using their respective individual

fields or by entering one finding in the long CD Ratio text field. Vertical – Click in field and select from picklist. To enter a value not listed, select the top

blank line and manually type free text. Horizontal – Click in field and select from picklist. To enter a value not listed, select the top

blank line and manually type free text. Cup to Disc Ratio - Click in the large field and select a cup to disc ratio value from the

picklist. To enter a value not listed, select the top blank line and manually type free text. 9 Document a detailed AMD exam of the macula (optional)

Instructions for documenting a detailed AMD exam can be found following this section. Click the AMD Detail active text link to open the AMD Detail exam pop-up template, where

you can view or document findings. After documenting findings, click Save & Close. On the Posterior Examination tab, the active text link to the AMD Detail pop-up template will

turn pink and have a solid wing ding to indicate that the template has information. 10 Document a detailed Vitreomacular exam of the macula (optional)

Instructions for documenting a detailed Vitreomacular exam can be found following this section.

Click the VitreMac Detail active text link to open the Vitreomacular Detail OPH pop-up template, where you can view or document findings. After documenting findings, click Save & Close.



On the Posterior Examination tab, the active text link to the Vitreomacular Detail pop-up template will turn pink and have a solid wing ding to indicate that the template has information.

11 To document a detailed Histo (Presumed Ocular Histoplasmosis) exam of the macula Instructions for documenting a detailed exam for Presumed Ocular Histoplasmosis can be

found following this section. Click the Histo Detail active text link to open the Presumed Ocular Histoplasmosis OPH pop-

up template, where you can view or document findings. After documenting findings, click Save & Close.

On the Posterior Examination tab, the Histo Detail active text link to the Presumed Ocular Histoplasmosis pop-up template will turn pink and have a solid wing ding to indicate that the template has information.

Note: The Histo Detail pop-up template and the AMD pop-up template are very similar, and some may prefer to use the AMD template.

12 Document a detailed BDR (Background [Non-Proliferative] Diabetic Retinopathy) exam of the macula (optional) Instructions for documenting a detailed exam for Background (Non-Proliferative) Diabetic

Retinopathy can be found following this section. Click the BDR Detail active text link to open the BDR Detail OPH pop-up template, where you

can view or document findings. After documenting findings, click Save & Close. On the Posterior Examination tab, the BDR Detail active text link to the BDR Detail pop-up

template will turn pink and have a solid wing ding to indicate that the template has information.

13 To document a detailed PDR (Proliferative Diabetic Retinopathy) exam of the macula Instructions for documenting a detailed exam for Proliferative Diabetic Retinopathy can be

found following this section. Click the PDR Detail active text link to open the PDR Detail OPH pop-up template, where you

can view or document findings. After documenting findings, click Save & Close. On the Posterior Examination tab, the PDR Detail active text link to the PDR Detail pop-up

template will turn pink and have a solid wing ding to indicate that the template has information.

14 Document a detailed Vascular Disorders exam (optional) Instructions for documenting a detailed vascular exam can be found following this section. Click on the Vascular Detail active text link to open the Vascular Detail OPH pop-up template,

where you can view or document findings. After documenting findings, click Save & Close. On the Posterior Examination tab, the Vascular Detail active text link to the Vascular Detail

pop-up template will turn pink and have a solid wing ding to indicate that the template has information.

15 Drawings

a) Click the Draw button to open a picklist of Retina-specific drawing backgrounds.





16 Generate Note - Click the Generate Note button to generate the Ophthalmology chart note, if desired at this point in documentation.

Note: All generated versions of a document are archived and are discoverable.

17 When you have finished documenting physical exam findings on the Exams tabbed template set, External, Slit Lamp, and Posterior tab templates: Use the sliding left navigation pane to navigate to your next template.

AMD Detail Exam A detailed exam of the macula for Age-Related Macular Degeneration can be documented from the Posterior Examination tab template by clicking the AMD Detail active text link found in the Macula section of the template. This detailed exam is optional.

Documenting a Detailed AMD Exam of the Macula

1 Click the AMD Detail active text link to open the AMD Detail OPH pop-up template (eyeAMDdetail), where you can view or document findings.

2 The template is organized with right eye (OD) fields on one side and the left eye (OS) fields on the other.



3 Click one or more check boxes to select findings in the upper half of the template. A summary statement will build as selected findings appear in the large read-only text field in

concatenated format. 4 Additional findings can be documented for the AMD exam elements by clicking in the fields and

selecting from picklists: Mixed CNVM Pathology location Severity/progress

5 Clicking the Clear button will clear out your selections and the displayed summary statement.

6 Comment – Additional comments can be entered by clicking in the field and typing free text.

7 To exit the AMD Detail pop-up template Click Save & Close to save and close the template.

- or –


On the Posterior Examination tab, the active text link to the AMD Detail pop-up template will turn pink and have a solid wing ding to indicate that the template has information.



Vitreomacular Detail Exam A detailed Vitreomacular exam of the posterior pole can be documented from the Posterior Examination tab template by clicking the VitreMac Detail active text link found in the Macula section of the template. This detailed exam is optional.

Documenting a Detailed Vitreomacular Exam

1 Click the VitreMac Detail active text link to open the Vitreomacular Detail OPH pop-up template (eyeVitMacDetail), where you can view or document findings.


3 Click one or more check boxes to select findings in the upper half of the template. If a finding has a text field to its right, click in the field and select a modifier from the picklist. A summary statement will build as selected findings appear in the large read-only text field in

concatenated format. 4 Clicking the Clear button will clear out your selections and the displayed summary statement.


6 To exit the Vitreomacular Detail pop-up template Click Save & Close to save and close the template.

- or –




On the Posterior Examination tab, the VitreMac Detail active text link to the Vitreomacular Detail pop-up template will turn pink and have a solid wing ding to indicate that the template has information.

Histo (Presumed Ocular Histoplasmosis) Detail Exam A detailed exam of the posterior pole for changes related to Presumed Ocular Histoplasmosis can be documented from the Posterior Examination tab template by clicking the Histo Detail active text link found in the Macula section of the template. This detailed exam is optional.

Documenting a Detailed Histo (Presumed Ocular Histoplasmosis) Exam

1 Click the Histo Detail active text link to open the Presumed Ocular Histoplasmosis OPH pop-up template (eyeHistdetail), where you can view or document findings.



concatenated format. 4 Additional findings can be documented for the POHS exam elements by clicking in the fields and

selecting from picklists: Mixed CNVM



Pathology location Severity/progress



7 To exit the Presumed Ocular Histoplasmosis pop-up template Click Save & Close to save and close the template.

- or –


On the Posterior Examination tab, the Histo Detail active text link to the Presumed Ocular Histoplasmosis pop-up template will turn pink and have a solid wing ding to indicate that the template has information.

Note: The Histo Detail pop-up template and the AMD Detail pop-up template are very similar, and some may prefer to use the AMD Detail template.

BDR (Background (Non-Proliferative) Diabetic Retinopathy) Exam A detailed exam of the posterior pole for changes related to Background (Non-Proliferative) Diabetic Retinopathy can be documented from the Posterior Examination tab template by clicking the BDR Detail active text link found in the Vessels section of the template. This detailed exam is optional.

Documenting a Detailed BDR (Background [Non-Proliferative] Diabetic Retinopathy) Exam

1 Click the BDR Detail active text link to open the BDR Detail OPH pop-up template (eyeBDRDetail), where you can view or document findings.




3 If there is information from a previous encounter, you can copy-forward the last documented exam findings by clicking the “Copy last exam” check box.


concatenated format. 5 Additional findings can be documented for the BDR exam elements by clicking in the fields and

selecting from picklists: Macular pathology Severity Changes/progression



8 To exit the BDR Detail pop-up template Click Save & Close to save and close the template.

- or –


On the Posterior Examination tab, the BDR Detail active text link to the BDR Detail pop-up template will turn pink and have a solid wing ding to indicate that the template has information.



PDR (Proliferative Diabetic Retinopathy) Exam A detailed exam of the posterior pole for changes related to Proliferative Diabetic Retinopathy can be documented from the Posterior Examination tab template by clicking the PDR Detail active text link found in the Vessels section of the template. This detailed exam is optional.

Documenting a Detailed PDR (Proliferative] Diabetic Retinopathy) Exam

1 Click the PDR Detail active text link to open the PDR Detail OPH pop-up template (eyePDRsubmenu), where you can view or document findings.


3 If there is information from a previous encounter, you can copy-forward the last documented exam findings by selecting the “Copy last exam” check box.

4 To document findings Click one or more check boxes to select findings in the upper half of the template. Click in the field(s) to the right of a selected finding and select a detail from the picklist that

launches. To enter a detail not listed, select the top blank line and manually type free text. A summary statement will build as selected findings appear in the large read-only text field in

concatenated format. 5 The following findings can be documented for the PDR exam:

NVD – Neovascularization disc NVE – Neovascularization peripheral Vitreous hemorrhage Severity



Location Changes/progression



8 To exit the PDR Detail pop-up template Click Save & Close to save and close the template.

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On the Posterior Examination tab, the PDR Detail active text link to the PDR Detail pop-up template will turn pink and have a solid wing ding to indicate that the template has information.

Vascular Detail Exam A detailed vascular exam can be documented from the Posterior Examination tab template by clicking the Vascular Detail active text link found in the Vessels section of the template. This detailed exam is optional.

Documenting a Detailed Vascular Disorders Exam

1 Click the Vascular Detail active text link to open the Vascular Detail OPH pop-up template (eyeVascularDetail), where you can view or document findings.




3 The Vascular Detail exam pop-up template is organized into sections Arteriosclerotic/Hypertensive changes Venous occlusive disease Arterial occlusive disease

4 As you make your selections, a summary statement will build as selected findings appear in the large read-only text field in concatenated format.

5 Arteriosclerotic/Hypertensive Changes Select the appropriate check box to indicate “Hypertensive retinopathy” and/or “Intraretinal

lipid”. 6 Venous Occlusive Disease

a) Click on the appropriate check box(es) to select conditions

b) For conditions with fields next to them, click in the field and select from the picklist. To enter a value not listed, select the top blank line and manually type using free text.

c) Venous Occlusive disease findings include:

BRVO – Branch retinal vein occlusion

CRVO - Central retinal vein occlusion

Secondary CME – Secondary cystoid macular edema

Vascular engorgement

7 Arterial Occlusive Disease

a) Click the appropriate check box(es) to select conditions

b) Location - Click in the field and select a location from the picklist. To enter a value not listed, select the top blank line and manually type using free text.

c) Severity - Click in the field and select a severity from the picklist. To enter a value not listed, select the top blank line and manually type using free text.

d) Arterial Occlusive diseases include:

Arterial plaque – Intra-arterial plaque

BRAO – Branch retinal artery occlusion

CRAO – Central retinal artery occlusion

Retinal edema – Secondary retinal edema

Vessel sheathing – Arterial vascular sheathing



10 To exit the Vascular Detail pop-up template Click Save & Close to save and close the pop-up template

- or –




On the Posterior Examination tab, the Vascular Detail active text link to the Vascular Detail pop-up template will turn pink and have a solid wing ding to indicate that the template has information.

Ophthalmology Drawing Module Drawings for documenting exam findings can be done using the Drawing Module.

1 Click the Draw button to open a picklist of Ophthalmology drawing backgrounds.

2 Select a background from the picklist and the Drawing Module will open with your selected background.

Note: The list of available backgrounds, when the retina specialty is selected, is different on the Posterior Examination tab than on the External Examination or Slit Lamp Examination tabs.

3 After completing your drawings, click the Save toolbar button to name the file and save it.

The picklists of Ophthalmology drawing backgrounds launched when you click the Draw button

On the Tech Exam tab (eyeTechExam), External Examination tab (eyeExternalExam) and the Slit Lamp Examination tab (eyeSlitlampExam) templates.



On the Posterior Examination tab (eyeRetinaExam) template.

Saving a drawing in the Drawing Module.



Procedures (Brief) The Procedures - OPH template (oph_core_procedures) provides a central location from which to launch diagnostics and other procedures for Ophthalmology.

For the Retina sub-specialty, there are Retina specific links to:

Retina Lasers

Retina Procedures

Retina Diagnostics

Intravitreal Injections

Reference: Procedures and Testing are covered in detail in the next chapter, which discusses workflow shared between Technicians and Providers.

In the following screen capture, the Retina related links are circled. All links on this template are specific to Ophthalmology. The General Ophthalmology procedure templates can be used if desired.



Impression and Plan The Plan - OPH template (oph_plan) provides a summary of all previously documented impression/plan information for the patient displayed in a data grid. To document a new impression/plan for the current encounter, click the Add button found below the Impression/Plan Summary grid, on the right.

All information is displayed in a data grid that can be expanded to see information that a row contains in detail.

Double-click on the row in the grid to open a pop-up template displaying the information found in the grid in a larger format.

Links above the grid give the provider easy access to key features, including:

Draw – a link to the Drawing Module Procedures – a link to the Surgery Scheduling template, where surgical procedures can be

scheduled. Task – a link to the standard Tasking pop-up template Provider Communications – a link to the Provider Communication pop-up template Patient Education – a link to launch the Patient Education materials picklist Patient Plan – a link to generate the Patient Plan document to be given to the patient at the end

of the encounter Chart Note – a link to generate the Chart Note document for the encounter Patient Portal Upload – a link to update certain information to the patient portal Impression/Plan – The Impression/Plan Summary grid will display historical impression and

plan data for the patient, in concatenated format for each encounter. Add button – Below the Impression/Plan Summary grid is an Add button which will launch the

OPH - Assessment/Plan pop-up template (oph_assess_plan), where impression/plan can be documented for the current encounter.

Expand button – Below the Impression/Plan Summary grid is an Expand button which will launch the Visit Summary – OPH template, which will display a history of summaries of encounters for the patient in concatenated format. Click the Return button to return to the Plan tab template.

Surgery Scheduling The Surgery Scheduling – OPH template can be launched from the Plan tab template by clicking on the Procedures active text link, or by selecting “Surgery Scheduling – OPH” when using Template Launcher found at the bottom of the History toolbar. A “Preop Exam” active text link to the provider’s Exam tab template is found on the Surgery Scheduling – OPH template.

At the top of the template, the Impressions data grid will display historical impressions for the patient in concatenated format. The Exam section will display exam findings for the current encounter. The IOL information section is used for cataract surgeries, and the Exam findings section is used for any refractive surgery, including cataract surgery.



The following shows the Surgery Scheduling – OPH template, page 1.



The following shows the Surgery Scheduling – OPH template, page 2.

Scheduling a Surgery in Ophthalmology 1 Type - At the top of the template, select the appropriate option for type of surgery being

scheduled.

2 Indication(s) – The Indication fields will display the chief complaint(s) documented in the three numbered CC fields found on the CC-HPI-ROS tab template (eyeChiefComplaint). You can also click in an available Indication field and select from the picklist. To document a value not listed, select the top blank line and manually type using free text. Note that the picklist launched by this field is the same for all types of Ophthalmology

surgeries. 3 Surgical procedure – The field immediately to the right of the first Indication field is used to

document the procedure to be performed at surgery. Click in the field and select from the picklist, or to enter a value not listed, select the top blank

line and type using free text. The choices of procedures on the picklist will be specific for the type (category) selected above.

4 Eye – Click in the field and select the eye the procedure is to be performed on. Choices include OD, OS, and OU.



5 When – Click in the field and select a description for when the surgery is to be scheduled from the picklist, or to enter a value not listed, select the top blank line and type using free text. Choices include: as soon as possible first available appointment in the next few weeks patient will contact surgical coordinator patient will decide

6 Combined procedure – To document a second procedure to be combined with the first, click in the field and select from the picklist. To enter a value not listed, select the top blank line and type using free text.

7 Eye – Select the eye to have the second, combined procedure to be performed on by clicking in the field and selecting from the picklist.

8 Co-managed patient – If the patient is being co-managed with another provider, click in the field and select from the dbpicklist. Enter a provider not listed by closing the dbpicklist and typing free text.

9 Referral source – If known, click in the field and select from the picklist, or to enter a value not listed, select the top blank line and type using free text.

10 Surgeon – If known, click in the field and type using free text.

11 The following information may not be known, and may have to be documented by the office staff with the responsibility for scheduling surgeries at the practice. Dates are selected from the Calendar dialog box and times are manually typed in. Surgery date Arrival time Surgery time Postop date Postop time

12 Comments/other information – Click on check boxes to select the appropriate items. A comment will automatically begin to build in the large text field to the right.

13 Instructions – Click on check boxes to select appropriate items. A comment will automatically begin to build in the large text field.

14 Pre-op medications section

a) Document medications to be administered to the patient pre-operatively by clicking in the field and selecting from the picklist, or to enter a value not listed, select the top blank line and type using free text. Not all types of medications will be administered, and medications documented here will not appear in the Medications Module.

Mydriatic

Non-steroidal

Antibiotics

Anesthesia



b) Location – Document the location where surgery is to be performed by clicking in the field and selecting from the picklist. Enter a value not listed by selecting the top blank line and typing free text.

c) Booked minutes – Enter the amount of time planned for surgery to be booked for the surgical suite in minutes by clicking in the field and using the onscreen numeric keypad.

15 Vital Signs – Previously documented vital signs will be displayed in the data grid. Enter a new set of vital signs by double-clicking on the grid to open the Vital Signs (Lite) pop-up template.

16 IOL information section This section is used to document details for the IOL to be implanted during cataract surgery. Enter a value not listed in a picklist by selecting the top blank line and typing free text. Fields with picklists that do not have a top blank line will not allow you to type in a value.

17 Exam section This information is necessary when the patient is being scheduled for refractive surgery,

frequently for cataracts, or other surgery, such as corneal transplant. Fields in this section are shared from the different Ophthalmology exam templates, Tech Exam

tab (eyeTechExam), Testing tab (eyeOtherTest), and Exam tab (eyeBriefExam). Click the Pre-op Exam active text link to open the Exam tab template, where you can view

previously documented exam findings. 18 Procedure Information

The Procedure information grid will display historical procedure information for the patient. When scheduling surgery, the information documented on this template will have to be added

to the grid. a) Click the “Surgery to do” check box to select it.

b) Click the Add to Grid button to add the details for the surgery being scheduled to the Procedure Information grid.

c) The Tasking dialog box will open for tasking. Select task recipients or click Cancel to close.

d) The scheduled surgery will be listed in the Procedure Information grid.

Note: A surgical procedure listed in the Procedure Information data grid will be available to the Ophthalmology ASC Visit Information template (eyeasc_sharedvalues) as long as both are within the same practice.

19 History and Physical

a) Click the “History and Physical” active text to open the Preop H&P – OPH pop-up template (eyePreopHandP).

b) Planned surgery date – Will display a previously selected surgery date.

c) Preoperative Physical Exam

Normal - To document normal findings, click the Normal check box to select. The Neck, Lungs, and CV system fields will automatically be populated with normal findings. HEENT and Other will not be populated.

Note: It is assumed that HEENT is not normal, therefore requiring surgery.



Abnormal – To document abnormal findings, click in the system field and select from the picklist, or to enter a value not listed, select the top blank line and type free text.

Other – Click in the other field and type free text to document other findings.

d) Click Save & Close to save and exit the template, or click Cancel to exit without saving. A Limited History and Physical Exam report document will be generated automatically. Review the report and close using the Close toolbar button.

20 Generate Note – Click the Generate Note button to generate the Preop Surgery Summary document.



The following shows the Ophthalmology ASC Visit Information tab template (eyeasc_sharedvalues). Highlighting the row in the grid will populate the corresponding fields found below the grid.



Provider Communications The following shows the Provider Communications pop-up template. This template is primarily used for provider communications with other providers.

Assessment/Plan The Plan tab template (oph_plan) is where a provider can view all previously documented impression/plan summaries for the patient.

To document a new impression/plan for the current encounter, click the Add button found below the summary grid to launch the OPH – Assessment/Plan pop-up template (oph_assess_plan)

General Workflow for Documenting Assessment/Plan

1 Open the Ophthalmology Assessment/Plan template by clicking the Add button found on the Plan tab template.



2 Select Today’s Assessment(s)

a) From the patient Clinical Problems List

b) Select an assessment using the Add or Update Assessments template

3 Document an Impression

4 Document a plan

a) Selecting an Ophthalmology Quick Plan

b) Using the Ophthalmology Plan Details template

5 Document patient's return visit to the clinic

6 Click "Add To Grid" to add the information to the grid



Select Today's Assessments

1 Click the Add button to launch the OPH Assessment/Plan pop-up template.

2 Assessments can be added to Today’s encounter in two ways:

a) Clinical Problems

If the patient has an active problem or chronic condition listed in the Clinical Problems data grid, you can add that problem to Today’s Assessments by highlighting the row in the grid and clicking on the “Add to Today’s Assessments” button.

The highlighted diagnosis in the Clinical Problems list will be copied to the Today’s Assessments data grid.

b) The Add or Update Assessments pop-up template

Click the Add button found below the Today’s Assessments grid to open the Add or Update Assessments template (Assessments).

Note: In NextGen KBM version 8.3, the Add or Update Assessments template is now seen as the Assessments tab template of the Assessments/Plan/Orders tabbed template set.

On the Add or Update Assessments template, you can select an assessment from: – Diagnosis history – patient’s list of diagnoses – Clinical problems – patient’s list of active problems and chronic conditions – My Favorites – provider’s list of frequently used assessments and diagnoses – Select a new assessment from the Common Assessment template

Look up a Diagnosis Code from the master search window.

Reference: See detailed instructions that follow for using the Assessments template.



Add or Update Assessments Template In NextGen KBM version 8.3, the Assessments template has been redesigned and enhanced, and made part of the Plan/Orders tabbed template set. This template is used for documenting or updating Today's Assessments.

Documenting on the Add or Update Assessments tab template (Assessments)

1 Review Today’s Concern/Reason for Visit – This will be pulled from the reason(s) for visit selected at the beginning of the encounter on the Intake – OPH template.

2 Add Assessments on 1-click – Selecting the check box for “Add Assessments on 1-click” will allow you to select an assessment or diagnosis from one of the grids on the template for Today’s Assessment with a single click, without having to click the Add/Update button. If this check box is not checked, then an item selected will appear in the middle of the template so that it can be updated for status/side and then added to Today’s Assessments using the Add/Update button.

Note: A setting for the “Add Assessments on 1-click” check box can be found in the Assessments section of the ngkbm_config practice template, which is used for configuring practice preferences for the system. This setting determines whether the “Add Assessments on 1-click” check box is selected by default or not. When this setting is selected, the “Add Assessments on 1-click” check box will be selected by default when the "Add or Update Assessments" tab template is opened.

3 Diagnosis History – The Diagnosis History section of the template will list active diagnoses for the patient. These can be selected for Today’s Assessment. Click the “Show Chronic only” check box to select to display only the patient’s chronic

conditions in the grid. Leave the check box unchecked to display all. To select a diagnosis from the Diagnosis History grid, single-click on the row in the grid with

the diagnosis you want to select. Edit the information (status/side) in the middle of the template. If the 1-click setting has been selected, a single-click will add the diagnosis to Today’s Assessments without clicking the Add/Update button will make the selection.

4 Clinical Problems – The Clinical Problems section of the template will list active tracked problems and chronic conditions for the patient. These can be selected for Today’s Assessment. Show Chronic - Click the “Show Chronic” check box to select to display only the patient’s

chronic conditions in the grid. Leave the check box unchecked to display all.



Show My Tracked problems – Click the check box for “Show My Tracked problems” to display only the patient’s problems that you are tracking. Leave unchecked to display all.

To select a diagnosis from the Clinical Problems grid, single-click on the row in the grid with the diagnosis you want to select. The information will be displayed in the middle of the template, where status/side can be edited. Click Add/Update to add the diagnosis to Today’s Assessments. If the 1-click setting has been selected, a single-click will add the diagnosis to Today’s Assessments without clicking the Add/Update button.

5 My Favorites – The My Favorites section of the template will display a list of assessments that the provider has selected for all patients. These might not be the most commonly used assessments, but might instead be assessments that were difficult to find. These can be selected for Today’s Assessment. Favorites Category – The Favorites Category Filter allows providers to organize their lists of

favorite assessments in different lists for ease of use. Click on the drop-down list for Favorites Category and select which category of saved favorite diagnoses to display. Select “All” to display all.

Filter – The Filter field allows you narrow your favorites list to what you are specifically looking for. Type in a few letters and the list will be refreshed to display those saved favorite assessments with descriptions that start with those letters.



To select a diagnosis from the My Favorites grid, single-click on the row in the grid with the diagnosis you want to select. The information will be displayed in the middle of the template, where status/side can be edited. Click Add/Update to add the diagnosis to Today’s Assessments. If the 1-click setting has been selected, a single-click will add the diagnosis to Today’s Assessments without clicking the Add/Update button.

6 To add a new assessment to Today's Assessments using the Common Assessments pop-up template

a) Click the “Add Common Assessment” active text to launch the new multi-specialty Common Assessments pop-up template.

b) Select a specialty – Click in the Common Assessments field and select Ophthalmology assessments “OPH Retina Assessments EYE” from the dbpicklist. This will load the template with a set of common assessments for Retina. These choices can be customized by the practice.

c) Selecting assessments

On the Common Assessments template, clicking on an assessment listed with a code will select the assessment and add it to the Today’s Assessments grid.

Assessments in bold without a code are assessment categories. Clicking on an assessment category will open a dbpicklist of assessments. Select an assessment from the category dbpicklist by clicking on it and then on OK.

d) Remove an assessment from the grid by highlighting the row and clicking the Remove button.



e) After selecting your assessments from the Common Assessments pop-up template, click Save & Close to save and exit the template.



7 To update an assessment in the Today's Assessments list The Today’s Assessment grid is filtered so the Description, Code, Status and Site will be

displayed in the left column. You can update an assessment’s description, status, site, impression, differential diagnoses and

add the assessment to the patient’s clinical problems list and the provider’s “My tracked problems list” and “My Favorites” list.

a) Highlight the row in the grid with the assessment, and its details will be displayed in the fields above the Today’s Assessments grid.

b) Dx Description – Click in the field and modify the description, if desired, by manually typing free text.

c) Status – Click in the Status field above the grid and select a status from the dbpicklist. The status will be added to the assessment and displayed in the grid on the left side with the assessment description and code.

d) Side – Click in the field and select the side(s).

e) Add assessment to – Select the check box corresponding to the list you wish to add the assessment to.

Clinical Problems – the patient’s list

My tracked problems – the provider’s list



My Favorites – the provider’s list; Click in the field and select which list of favorites to add to or type a new category using free-text.

f) Click the Add/Update button to update the assessment with any changes or new details, and add the assessment to the selected lists. (This is not the same as documenting an impression.)

The following screen capture an example of updating one of Today's Assessments on the "Add or Update Assessment" tab of the Plan/Orders tabbed template set. This Core template launches when you select to add or update an assessment from the Ophthalmology Assessment/Plan template by clicking the Add button found below the Today's Assessments grid. You would choose go to this template if you are on the Oph - Assessment/Plan pop-up template and want to add another assessment to Today's Assessments or update an existing assessment.

8 To sort assessments in the Today's Assessments list

a) Click the Sort button to launch the Reorder Assessments pop-up template.

b) Start with the assessment that you want to be displayed in the list first.

Click on an assessment in the Existing Sort Order grid (upper grid), which displays assessments in their current sort order.

c) Clicking on an assessment in the upper grid will automatically move it to the first available row in the lower grid for New Sort Order.

d) Click on the assessments in the upper grid in the order you want them to appear in the lower grid one at a time.



e) Undo Last – Clicking the “Undo Last” button will undo the last assessment move; “Undo All” will undo all assessment moves.

f) When you have finished copying assessments from the upper grid to the lower grid in the new order you want them to be in, click Save & Close to save the new order and exit the template, or click Cancel to exit without saving.

9 To remove an assessment from the Today's Assessments list

a) Click on a row in the Today’s Assessment grid to highlight an assessment.

b) Click the Remove button.

10 After you have finished selecting and updating assessments for Today’s Encounter, click Save & Close to save and close the template, or click Cancel to exit without saving.

11 You will be returned to the OPH – Assessment/Plan template.



Document Impression After selecting assessments for Today’s encounter, return to the OPH – Assessment/Plan pop-up

template to document impressions.

Most impression details can be documented by clicking in the field and selecting from picklists. To enter a value not listed, select the top blank line and manually type using free text.

Alternatively, or in addition, you can type free-text in the large Impression Details field.

Prior to entering an impression, the provider may wish to refresh their memory about findings from today’s encounter. (For example, IOP, VA, etc.) Click the Patient Summary active text link in the Impression section to view this information.

1 Single-click on one of Today’s Assessments, and that assessment will be displayed in the Impression section.

2 In the Impression section, enter the side if not previously entered.

3 Information can also be entered for the following, if desired: Condition Symptoms Vision Impression Status

4 Information can be entered in the Impression Details field by typing free text, or My Phrases can be used.

5 Information entered in the Condition, Symptoms, Vision and Impression fields will appear in the Impression Details field. Impression details will be added to the grid when the "Add To Grid" button is clicked after documenting both the Impression and the Plan.



6 Click the Clear button to clear out all fields in the Impression section of the OPH – Assessment/Plan template.

Document a Plan A Plan for the patient can be documented in the Plan section of the OPH – Assessment/Plan pop-up template. The Plan section has links to the following:

Cataract Post-Op Complications

BMI Plan

Quick Plan

Plan Details

Order Sets

My Phrases



Quick Plan The easiest way to document an Ophthalmology plan is to click the Quick Plan active text link.

Clicking the link will launch a dbpicklist of plans for common ocular conditions. These plans can be customized at the practice level, or they can be edited at the individual patient level.

1 Click the Quick Plan active text in the Plan section of the OPH-Assessment/Plan pop-up template to launch the dbpicklist of quick plans available in the system for ophthalmology.



2 Click on a plan in the list, and its details will automatically populate the Today’s Plan field in concatenated paragraph format.



Plan Details The Ophthalmology Plan Details pop-up template allows you to easily document a detailed plan by clicking on check boxes to select the appropriate details. As you select details from different sections of the template, a summary statement will be built and displayed in the large Plan summary field found at the bottom of the template.

1 Click on check boxes in the following sections as appropriate to document a detailed plan: General discussions Medications Glasses/Contact Lenses Surgery Procedures Patient Instructions Tests Completed Today IOP Control

2 Education Material

a) When you click on the check box for “Education material provided”, a multi-select picklist will launch.

b) Select education materials provided to the patient from the picklist

c) Click on Close when done to exit the picklist.

3 Follow up Next Visit



a) When you click in the Return to clinic field, a series of picklists will automatically launch.

b) Return Days – Select the number of days, weeks, months or years to return to the office in

c) Return to Clinic Time – Select the unit of time (days, weeks, months or years) for return to clinic

d) Appointment with (provider) – Select the provider to schedule the return visit with (This list of providers must be set up by the practice.)

e) Return Exam Type – Select the type of exam to be performed on return visit; this is a multi-select picklist so click Close to exit after you have completed selections.

f) Click the Clear button to clear out the Return to clinic field and enter information again.

g) Click Save & Close to return to the OPH – Assessment/Plan template

4 Click on the Add to Grid button when you have completed documenting an Assessment, Impression and Plan.

The following screen capture shows the OPH – Assessment/Plan pop-up template after documenting Today’s Assessments, Impression, and Plan information.



The following screen capture shows the bottom half of the OPH – Assessment/Plan pop-up template, focusing on the Impression, Plan, and Impression/Plan Summary sections. In this example, the Impression and Plan details shown in the previous screen capture have been added to the Impression/Plan Summary grid by clicking the Add to Grid button found above the grid on the right.



In the following screen capture we see the Retina Ophthalmology Plan tab template, displaying the Impression/Plan Summary grid with new impression and plan information based on our example. The top two rows show example impression and plan summary information when using the Plan Details template, and the bottom two rows show example impression plan information when using the Quick Plan.

Order Sets On the OPH – Assessment/Plan pop-up template, there is an “Order Sets” active text link in the Plan section that launches the My Plan tab of the Assessments/Plan/Orders tabbed template set. Templates included in this tabbed template set include:



Assessments – also known as the Add or Update Assessments template; used to document assessments for the patient (Today's Assessments)

My Plan – the customizable My Plan (order_custom_plan) template based on order sets for diagnosis categories that can be modified and managed by clients using practice templates; diagnosis categories are part of a reference system

A/P Details – the Assessment/Plan Details template allows the provider to document impression, differential diagnoses, and plan details including follow-up for a selected assessment using free text, My Phrases, Common Phrases or Dictation. Common Phrases will have to be configured prior to use, while My Phrases can be created and managed on-the-fly by the provider. This is not generally used by Ophthalmology because the 'Oph-Assessment/Plan' template has Ophthalmology-specific information on it.

Labs – the Lab Master template used for placing and managing lab orders.

Diagnostics – the Diagnostics Studies template used for ordering and managing diagnostic radiology studies, such as X-rays, CT scans, MRI, Nuclear Medicine and Ultrasound.

Referrals – the Referrals Order template is used to place orders for referrals to other specialists, diagnostics studies, therapies, and durable medical equipment.

Office Procedures – the Office Procedures template is used to order office procedures and service items such as supplies, office medications, infusions, and injections; durable medical equipment such as splints, and office treatments, such as immunotherapy for allergies. This is not generally used by Ophthalmology.

Order Cosign – the Cosign/Review Orders template is used by supervising providers to review and co-sign/sign-off orders



The My Plan tab template (ord_custom_plan) is an ordering template where orders can be placed based on client customizable order sets. Order sets are based on disease categories that assessments belong to. When you highlight an assessment in the upper left of the My Plan tab template, orders belonging to the order set for the disease category that the selected assessment belongs to will be displayed on the templates for each type of order.

1 Highlight an assessment in the upper left of the template.

2 Click on the check boxes to select items to be ordered.

3 To select an order item not displayed Click the blue down-arrow of an available field in the order type section to launch a dbpicklist

of all items available in the system for that type. Locate the item you wish to order in the dbpicklist, highlight it and click OK. The selected item

will be displayed in the field. You must click the check box corresponding to the item to be ordered to select it.

4 Click the Place Order button to place the orders.



5 When you place orders for labs and radiology diagnostic studies, you or someone from your office (your delegate), will have to process and submit them to the Orders Module by clicking the “Lab/Diagnostics/Radiology Order Module Processing” active text link found in the lower right corner of the template to launch the Process and Submit Lab/Radiology Orders pop-up template. (This active text link will turn pink with a solid wing ding to indicate that orders are waiting to be processed.)

When you have opened the Assessments/My Plan/Orders tabbed template set, you can choose to place orders using the customizable My Plan template or from one of the individual orders templates in the set, including Labs, Diagnostics, Referrals, and Office Procedures. Placing orders from these templates works in a similar way:

1 Select the assessment to be associated with the order(s).

2 Select your order(s) by clicking on the radio button or check box corresponding to the item you wish to order.

3 Click the Place Order button.

4 Orders for labs and radiology diagnostic studies will have to be processed and submitted to the Order Module.

5 Orders for ophthalmologic tests are ordered using Tests/Future Tests links.



Cataract Post-Op Complications On the OPH – Assessment/Plan pop-up template, there is a new “Cataract Post-Op Complications” active text link in the Plan section that launches a new pop-up template used to document post-operative complications of cataract surgery.

Physician Internal Notes Below the Impression/Plan Summary grid is a section called 'Physician internal notes'. Information entered here will not display in the Chart Note, but will be seen on the Provider Start tab template on all subsequent visits. You can enter information using My Phrases or by typing free-text.



Coding The Coding - OPH template is where E&M Coding is calculated and charges are submitted to billing. Before submitting to billing, you can review E&M Coding calculations and override if appropriate, document and bill for counseling services, and link procedures to an appropriate diagnosis and select billing.

Navigate to the Coding - OPH template by clicking on the Coding top tab or the link in the sliding left navigation pane.

At the top of the template, verify the following previously documented details:

Visit type – verify visit type displayed in the grayed-out read-only field. This information was entered on the CC-HPI-ROS tab template.

In Ophthalmology, providers have a choice of selecting to use an E&M Code that has been calculated or to use one of the codes specific to Ophthalmology often referred to as “Eye Codes”. A calculated E&M code will display when you click the Calculate Code button.

Review/Update Today's Assessments The Today’s Assessment grid will show previously documented diagnosis/assessments selected for the patient for this encounter.



To Add an Assessment/Diagnosis

1 Click the Add button to launch the Add or Update Assessments pop-up template (part of the assessments/Plan/Orders tabbed template set)

- or -

Click the Add Common Assessment active text link to launch the multi-specialty Common Assessments pop-up template.

2 Select the assessment(s) you wish to add for the patient.

3 On the Assessments pop-up template, click on the Add/Update button to add a selected assessment to the Today’s Assessments grid.

4 Click Save & Close to save and exit the template

- or -

Click on Cancel to exit the template without saving.

Note: A diagnosis added on the Coding template will not appear in the Impression/Plan Summary grid. However, it will be seen in the Diagnosis History and in the Chart Note for the visit.

To Modify a Diagnosis

1 Click on the row in the Today’s Assessment grid to highlight the diagnosis.

2 Click the Edit button to launch the Assessments tab template.

3 Details for the highlighted diagnosis will be displayed in the edit fields above the Today’s Assessments grid.

4 Make any changes and click the Add/Update button.

5 The changes made will be reflected in the Today’s Assessments grid.

6 Click Save & Close to save and exit the template

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Changing the Order in which Diagnoses are Displayed

1 Click the Sort button to launch the Reorder Assessments pop-up template.

2 In the upper grid displaying the Existing Sort Order, click on each assessment in the order that you wish to see them displayed.

3 The assessments will be moved as you click them to the first available row in the lower New Sort Order grid.

4 Clicking the Undo Last button will undo the last assessment move, putting it back in the upper grid.

5 Clicking the Undo All button will undo all assessment moves, returning all assessments that were moved to the lower grid back to the upper grid in the same order they were in when you started.

6 After you have finished, click Save & Close to save and exit the template

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Procedure/Test Billing The Procedure Billing section on the Coding tab template is where a provider handles the procedure billing for Ophthalmology, including linking procedures to one or more diagnoses.

When the Procedures/Tests grid has been loaded, it will display procedures performed during the encounter. The first time you navigate to the Coding tab template, procedures will be loaded automatically.

If you have to make any changes to any of the information on the test and procedure templates, you will have to reload the grid by clicking the Load Procedures button.

After reloading the Procedures grid, any previous changes or edits that had been made to the items already listed in the grid using the Procedures Billing pop-up template will have to be entered again.

Review procedures listed in grid

a) Click on the check box to indicate:

No procedures for this encounter

Procedure only encounter

To bill for both encounter and procedures, do not make a selection

b) If procedures are listed in the grid, perform steps to link procedures to assessment(s)/diagnoses. (This is described in the next section.)



Linking Tests/Procedures to Assessments Each procedure or test item listed in the grid must be linked to an assessment for billing purposes.

For treatment procedures, this is done automatically.

For diagnostic tests, this must be done manually using the Procedure Billing extended pop-up (procedure_billing_vw_c) by double-clicking on the row in the Procedures/Tests data grid.

1 Double-click on the Procedures/Tests data grid to launch the Procedure Billing extended pop-up template (procedure_billing_vw_c).

2 To link the test/procedure to assessments

a) Click the radio button corresponding to the appropriate assessment in the Today’s Assessment section of the Procedure Billing pop-up template.

b) Click in the first available numbered Diagnosis (“Dx”) field.

c) The assessment code will populate the Dx field. There are eight numbered Dx fields, allowing you to assign up to eight assessments to each test or procedure.

3 Enter procedure modifiers

a) There are also four numbered Modifier (“Mod”) fields allowing users to assign up to four procedure modifiers.

b) Click in the first available numbered Mod field and select from the dbpicklist.

For single diagnostic tests or treatment procedures that have been performed twice during the same encounter, two separate rows will be automatically created in the grid, one with a modifier for the right eye (“RT”) and the second with a modifier for the left eye (“LT”).

For example, a test done separately on each of two eyes such as an A-scan will result in two separate line items (rows) to be submitted for billing.

Tests and procedures that by definition are performed on both eyes, or which include the term “bilateral”, will have a single billing row. In these cases, it is important to note that the modifier “50 bilateral procedure” need not be applied.

Tests and procedures that bill the technician and provider (interpretation) components separately, such as Visual Fields, will have each component listed on a separate row in the grid, for a total of two rows.

If a procedure is not to be billed, it should still be entered in the Procedures/Tests grid so that the practice can track what is done. In such cases, the 'Submit Charges' check box can be left un-selected for that particular procedure.



Note: If a practice wants to bill tests and procedures differently, they can manually make changes on the Coding - OPH template through the use of modifiers on the Procedure Billing pop-up template. For example, if a test or procedure is listed in the grid with two billing rows and the practice prefers to bill with a single charge, then the practice can use modifiers and combine the two rows into a single billing item by selecting the appropriate modifiers for the first row and removing the unnecessary second row.

Medical Decision Making The Medical Decision Making section is where a provider selects the level of complexity for medical decision making for the encounter or documents time spent counseling the patient if greater than 50% of the encounter time. In addition, the Counseling section can be used to document patient education, if not done elsewhere.

1 Medical Decision Making – If E&M coding is being used, click the appropriate radio button to select: Straight forward Low complexity Moderate complexity High complexity

2 Counseling Click the radio button for “Counseled > 50% of time and documented content” Total visit time (minutes) – Click in field and select the total time in minutes Total counseled time (minutes) – will be calculated automatically based on information

entered on the Counseling Details pop-up template. Document counseling details by clicking the Counseling Details active text to launch the

Counseling Details pop-up template.



Documenting Counseling Details

To document counseling details:

1 Click the Counseling Details active text to open the Counseling Details template.

2 In the Counseling/Education Details section, document a counseling item by row of fields: Type of counseling - Click in the first available field labeled “Type of counseling” and select

from the picklist. To enter a value not listed, select the top blank line and manually type using free text.

Method of counseling - Click in the first available field labeled “Method of counseling” and select from the picklist. To enter a value not listed, select the top blank line and type using free text.

Evaluation of counseling - Click in the first available field labeled “Evaluation of counseling” and select from the picklist. To enter a value not listed, select the top blank line and type using free text.

Enter the number of minutes spent on this counseling item. Other counseling can be documented as needed. The name of the logged-in user will populate the Counselor field. Today’s date will populate the Date field. Multiple people in the practice can make entries on this template.



3 Comments – Enter comments by clicking in the field and typing free text. There are two Comments fields.

Note: For billing and documentation purposes, the steps described above are the only required fields.

4 Education materials – Document education materials provided or used by clicking in the field and typing free text.

5 Interpreter – Click the “Interpreter used” check box to indicate that an interpreter was used Language – Click in the field and select from the picklist. To enter a value not listed, select the

top blank line and type free text. Interpreter’s name – Click in the field and type free text. Relationship – Click in the field and type free text.

6 Counseling/Education Factors

Note: Counseling/Education factors information is often documented for Joint Commission or other regulatory reviews.

Select “Detailed document” or “Reviewed” radio button. Readiness to learn – Select the appropriate check box. Barriers to learning – Select the appropriate check box. If selecting “Other”, manually type in

detail using free text. Learning preferences – Select the appropriate check box. If selecting “Other”, type in detail

using free text. 7 Cultural/Spiritual needs – Select the option “No” or “Yes”, then click in the text field and enter

details by typing free text. Marital status – Previously documented information will be displayed. Race – Previously documented information will be displayed. Religion – Previously documented information will be displayed.

8 After documenting counseling details, click Save & Close to save and exit the template

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Submit Code In the Submit Code section, you can calculate the E&M Code and submit it.

If you wish to use the Eye Codes for billing, you must manually select the appropriate code in the Eye Codes section.

1 View the calculated E&M Code by clicking the Calculate Code button. This will automatically populate all of the fields in the detailed EM History section used in

calculating a code. The gray Calculated Code field will display the calculated E&M Code. If any procedure listed in the grid does not have an associated diagnosis code, an error

message will appear.



2 To use an Eye Code, click the radio button for the appropriate code to select it. The selected code will be displayed in the gray Submitted Code field.

3 If this visit was a procedure-only visit, then the “Procedure only encounter” check box should be checked and the “Submit Procedures Only” button below the Procedures grid on the right should be clicked to submit just these procedures for billing.

4 Click the Fee Ticket button to generate a Fee Ticket document for the encounter, if needed by the practice.

5 Click the Submit Code button to submit code and billing.



Note: Many practices do not generate a fee ticket. Submitted procedures will be indicated as submitted in the Procedures grid. When an E&M code or an Eye code has been submitted, the word “Submitted” will appear on the Coding template to the right of the “Submitted Code” field. In addition, when procedures are submitted, the words “Procedures submitted” will appear above and to the right of the Procedures grid.



Generate Chart Note 1 Click the Chart Note active text link found at the top of the Plan tab template.

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Click the Preview button at the bottom of the left navigation pane

2 After the report has been generated, review it, sign it by clicking the blue check mark in the upper right corner, and then click the Close toolbar button. Save if prompted.

Note: It is a recommended best practice that after completing the documentation of an Ophthalmology encounter, all reports and documents are generated. For ASC patients, it is recommended that all open templates are closed and that the encounter is locked.



In the Retina Ophthalmology sub-specialty, the Procedures tab template (oph_core_procedures) is the central location for launching Ophthalmology specialty diagnostic testing and procedure templates. Workflow for Retinal testing and procedures is shared between the provider and the technician.

With Retinal diagnostic testing, there is a technical component that is performed by the technician and a professional, interpretation component that is performed by the provider. Retinal office procedures are ordered and performed by the provider.

In this chapter, we will cover the workflows for Retinal diagnostic testing and office procedures.

Procedures Template The Procedures - OPH template (oph_core_procedures) provides a central location from which to launch diagnostic and other procedures for Ophthalmology, General and Retina.

For the Retina sub-specialty, there are Retina specific links to:

Retina Lasers

Retina Procedures

Retina Diagnostics

Intravitreal Injections

In addition, some Retina specialists might use the General Ophthalmology procedure templates, launched by links listed on the left side of the Procedures - OPH tab template, including:

Posterior Laser - General Ophthalmology template used when performing more than one laser procedure during a visit

Office Procedures

Generic Office Procedures template

OCT - the General Ophthalmology template

C H A P T E R 8

Procedures - Workflow Shared Between Providers and Technicians

Chapter 8 Procedures - Workflow Shared Between Providers and Technicians


You can access this template in two ways:

Clicking the top Procedures tab when you have the Ophthalmology 10-tab template set open

Clicking the Procedures link in the left navigation pane

In the following screen capture, the Retina specialty related links are circled. Diagnostic testing and office procedures listed on the left side of the template are used by General Ophthalmology and by some Retina specialists. All links on this template are specific to the Ophthalmology specialty.

Retinal Testing and Procedures Workflows Workflow for Retina testing and procedures is shared between the provider and the technician.

Workflow Summary

1 The provider orders tests and procedures.

2 The provider tasks the technician with testing.

3 The technician performs testing and notifies the provider when testing is completed.

4 The provider interprets the results of testing.

5 Laser procedures are performed by the provider.



Scheduling and Tasking Retinal Tests and Office Procedures There are two Ophthalmology specific Tasking pop-ups templates that are used to schedule tests and office procedures for today and in the future. Scheduling and tasking is performed by the provider.

Task Tests – OPH pop-up template is used to schedule and task the technician for test and procedures to be performed today. This template is launched by clicking the Schedule button when it is found in a template section referring to testing during today’s encounter, or by the link in the left side navigation pane 'Tests Today'.



Task Future Tests – OPH pop-up template is used to schedule and task the technician with tests and procedures that will be performed at a future date. This template is launched by clicking on the Schedule button when it is found in a template section referring to future testing, or by clicking the 'Future Tests' link in the left side navigation pane.

These two templates are launched by clicking the Schedule button found on the following templates:

1 Retina Office Procedures – Lasers – OPH (retOfficeProcedure) This template is launched from the main Procedures tab template when you click the Retinal

Lasers active text link The Schedule buttons are found in the Return Visit section found in the lower right of the

template 2 Retina Office Procedure – Other – OPH (retOfficeProcOther)

This template is launched from the main Procedures tab template when you click the Retinal Procedures active text link

The Schedule buttons are found in the Return Visit section found in the lower right of the template

3 Request Diagnostics tab (retRequestDxTest) of the Retina Diagnostics 4-tab template set This template is opened from the main Procedures tab template when you click the Retinal

Diagnostics active text link to launch the Retinal Diagnostics tabbed template set. The Schedule buttons are found below the Tests Scheduled Today and the Schedule Future

Tests data grids.

Scheduling Tests and Tasking a Technician

On the Task Tests or Task Future Tests pop-up templates, details for testing and the tests to be performed can be documented.



1 Priority - Normal priority is the default. Change the priority by clicking in the field or on the blue down-arrow and selecting from the picklist.

2 Indication - Click in the field and select from the picklist. To enter a value not listed, select the top blank line and type using free text.

3 Subject - "Test Request" will be displayed by default. The subject can be changed by clicking in the field and using free text.

4 Description - A short description can be entered by clicking in the field and typing free text.

5 Patient - The name of the patient currently open will be displayed.

6 Comment - A comment can be entered by clicking in the field and typing free text.

7 Attach a template? - Select the option "Yes" or "No". "Yes" will be selected by default, and will allow you to attach a template with patient information to the test when it is tasked to the technician.

8 Select tests - Click on the check boxes corresponding to each of the tests to be scheduled. For some tests, select the eye(s) the test is to be performed on by clicking in the field corresponding to the test and selecting "OD", "OS", or "OU" from the picklist.

9 Study eye - Select the eye to be studied by clicking in the field and selecting "OD", "OS", or "OU" from the picklist.

10 Transit - Click in the field and select transit order (order for testing). To enter a value not listed, select the top blank line and type using free text.

11 Location - This field will be visible if FA or ICG is selected. Refers to location of eye, such as peripheral photos, or more details, such as possible laser. Click in the field and select from the picklist. To enter a value not listed, select the top blank line and type using free text.

12 Select "Add billing codes for today" by clicking on the check box.

13 If appropriate, select that "Patient may leave after test." by clicking on the check box.

14 After you have entered all information needed, click the Save & Task button

15 (Optional) Attaching a template - If you have selected "Yes" to attach a template, the Attach dialog box will appear where you can select an item, such as a completed template or generated document, to attach to the test request. (You can also select “No Attachment.”)



16 Tasking will open to the Select Task Recipients window, where you can select the technician to be tasked with the scheduled tests.

Consent Forms 1 Click the Consent Forms active text to open the Consent Forms – OPH pop-up template

(eyeConsentFormPopup). This active text link can be found on the office procedure templates, such as Retina Office Procedure – Other and Retina Office procedure – Lasers.

2 The patient’s name will be displayed at the top of the template.

3 Click in the “Consent by” field to open a picklist of choices of who is giving consent: patient, parents or guardian. The blank line at the top of the picklist can be selected, and information not listed can be entered by typing free text.

4 Consent Date and Time will display the current system date and time when the template was opened.

5 Indication(s)

a) Click in the first available Condition field to launch the Diagnosis Search dialog box.

b) Select which category of diagnoses to search for a diagnosis.

c) Click on the diagnosis to be associated with the procedure on the right side list.

d) Click the Select button.

e) Select the eye from the picklist that automatically launches.



f) Repeat to select all conditions to be associated with the procedure.

6 “Conditions have been explained by” will display the currently selected provider’s name.

7 Searching for a Procedure

a) Click in the first available procedure field on the Consent Form –OPH pop-up template to launch the Procedure Search dialog box.

b) Type in a few letters of the procedure or a word in the Description field.

(If the proper name of the procedure is unknown, using the asterisk * symbol before and after the entry will search for that entry anywhere in the description.)

c) Click the Search button. The list displayed on the window will be refreshed.

d) Click on the procedure in the list and click OK to select.

e) Select the eye from the picklist that automatically launches.



f) Repeat to select all procedures to be performed.

8 Procedure Date and Time will default to the current system date and time. This can be changed by clicking in the fields and selecting from the pop-ups that open.

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Click on the check box “To be scheduled in the near future.”

9 Standard Risks – This is a list of the standard risks for any procedure. Click on the check box of items that apply to select.

10 Specific Risks – This is a list of risks specific to Ophthalmology procedures. Click on the check boxes to select items that apply.

11 Other risks - can be entered by clicking in the field and typing free text

12 Check List – This is a list of items to document prior to the procedure, including information given and the patient’s understanding of the procedure.

13 Comments - can be entered by clicking in the field and typing free text

14 Tasking – Click the Send Task button to launch the Tasking dialog box.

15 Click Save & Close to save and exit the template. The Consent Form document will be generated automatically. To Exit without saving, click on Cancel.

16 Once the consent is generated, it can be printed, signed by the patient, and scanned back into the chart.

Note: Some practices have signature pads so that the patient can sign the consents without having to print the forms.



Patient Dilation and Other Medications (Eye Drops) The Patient Dilation/Other Medications grid can be found on the Tech Exam tab template (at the bottom), and the Perform Test tab of the Retina Diagnostic Tests tabbed template set. Dilation and other medications administered to the patient can be documented by clicking the Add/Update button to launch the 'Dilation/Other Medications - OPH' pop-up template. If the patient was not dilated, this can be documented along with a reason for not doing so.

Documenting Patient Dilation

1 Click in the Dilated field and select eye drops administered for dilation from the picklist, or to enter drops not listed, select the top blank link and type free text.

2 Click in the Eye field and select which eye was dilated or both eyes. Choices are: OD, OS, OU.

3 Selecting the medication and eye(s) will automatically populate the Time of dilation and By fields with the current system time and the currently logged in user.

4 Select the check box to indicate "Patient and/or parent/guardian was advised of all side effects associated with dilation".

5 Click Add to add the dilation information to the grid.

If a patient was not dilated, this can be documented using fields in the Dilation section to document the reason why dilation was not done.

Documenting the Reason a Patient was not Dilated

1 Select the check box to indicate "The patient was not dilated".

2 Click in the "Reason patient not dilated" field and select from the picklist, or to enter a reason not listed, select the top blank line and type free text.

3 Click in the Eye field and select which eye was not dilated or both eyes. Choices are: OD, OS, OU.

4 Selecting the reason and eye(s) will automatically populate the By field with the currently logged in user.

5 Click Add to add the dilation information to the grid.

If other medications were administered to the patient, these should be documented, using the fields in the Other medications section, immediately below the Dilation section.

Documenting Other Medications

1 Click in the Name field and select eye drops administered from the picklist, or to enter drops not listed, select the top blank link and type free text.

2 Click in the Eye field and select which eye or both eyes had drops administered. Choices are: OD, OS, OU.



3 Selecting the medication and eye(s) will automatically populate the Time of dilation and By fields with the current system time and the currently logged in user.

4 Enter a comment in the Comments field by clicking in the field and typing free text.

5 Click Add to add the medication information to the grid.



Retinal Lasers On the Procedures – OPH tab template (oph_core_procedures), click the “Retinal Lasers” link to launch the Retina Office Procedures – Lasers – OPH template (retOfficeProcedure). Laser procedures are performed by the provider.

Documenting a Retinal Laser Procedure

Workflow starts in the upper left of the template and flows down and across for each section.

1 Complete consent – Click the Consent Forms active text to open the Consent Forms – OPH pop-up (eyeConsentForms).

2 In the upper section of the template, complete the following by clicking in the field and selecting from picklists Category –.Click in field and select from picklist Diagnosis – Click in field and select from the Diagnosis Search dialog window that is

launched Anesthesia – Click in field and select from picklist Procedure – Click in field and select from picklist Code – field is associated with procedure and will be populated automatically

3 Pre-procedure care – Click on the check boxes to select appropriate items

4 Procedure Information



a) Within 90 day PO period for same Tx and same eye – Click on the check box to select “No” or “Yes”

b) Goals – enter laser indication by clicking in the field and selecting from the picklist. To enter a value not listed, select the top blank line and manually type using free text. Select which eye the procedure will be performed on.

c) Eye – Select which eye the procedure will be performed on. If treatment eye has already been entered, it will be displayed here.

d) Surgeon – will automatically display the currently selected provider in the toolbar

e) Tech – Click in the field and select from your customized picklist of technician names, or close the list and type using free text.

f) The data grids at the bottom of the template for Best Visual Acuity, Vital Signs, Ocular History, Allergies, and Ocular Medications can be referred to as needed.

g) Preop IOP – Enter values for OD and OS, then click the Save button. If values for IOP have already been entered, they will be displayed here.

h) Mood/Affect – Click on the radio button to select “Normal” or “Abnormal”

i) Orientation – Click the radio button to select “Oriented x3” or “Abnormal”

j) Vital Signs – Double-click on the grid to launch the Vital Signs pop-up to document vital signs or click on the “Postop vitals waived by surgeon”

5 Laser treatment and details

a) Laser TX - Click on a check box to select the appropriate laser treatment

Selecting a check box for Laser TX (laser treatment) will automatically populate other laser detail fields. Default values will be based on what was treatment was selected.

b) Additional details that may populate automatically include:

Lens system

Laser Type

Shots

Power

Duration

Spot size

Treatment return (TX Return)

Comfort

Notes

c) When check boxes are selected from the Laser Tx and Laser Type sections, information will populate the laser settings fields and a note will begin to be generated in the Notes field.

d) Add any additional information to the note by manually typing in free text. You can also clear out the Notes field and type in your own note using free text.

6 Laser and treatment details can also be changed or added to manually.



7 Black Screen button – The Black Screen button is found on the right side of the template above the Notes field. When the Black Screen button is clicked, the computer screen will temporarily turn black with

a small OK button in the lower right corner. Clicking the small OK button in the bottom right corner of the darkened screen will return you

to the templates and your workflow. 8 No complications/Complications – Click on the “No complications”check box to select or

document any complications in the adjacent field using free text.

9 Add to History – Click the Add to Histories button to add this procedure to the Ocular History grid. (History master)

10 Postop IOP – Enter values for OD and OS, then click the Save button. (Found below the Pre-op IOP fields, in the middle of the template.)

11 Vital Signs – Double-click on the Vital Signs grid to launch the Vital Signs pop-up template to document post-operative vital signs, or click on the “Postop vitals waived by surgeon”.

12 Discharge Instructions – Click the Discharge Instructions active text to open the Discharge Instructions – OPH pop-up template (eyedischargeinstruct). Click on a check box to select an instruction document to generate. Click Save & Close to generate the document and exit the template.

Note: Only one Ophthalmology Instruction document can be generated per encounter.



13 Return visit

a) Photos today – Click the Schedule button to open the Task Tests – OPH pop-up template (eye_tasktests), where you can select and task various Ophthalmology procedures and tests. Click Save & Close to save and exit the template.

b) Future tests – Click the Schedule button to open the Task Future Tests – OPH pop-up template (eye_tasktestsfuture), where you can select and task various Ophthalmology procedures and tests to be performed in the future. Click Save & Close to save and exit the template.

c) RTC (Return to Clinic) – Click in the field and select from the picklist. To enter a value not listed, select the top blank link and manually type in using free text.

14 Draw – Click the Draw button to launch a picklist of Ophthalmology drawing backgrounds. The Draw Module will open automatically. After documenting findings on drawings, click Save & Close.

15 When the procedure has been completed, click the Generate Note button found in the lower right corner of the template. This will generate a separate procedure note.

Retinal Procedures (Other) On the Procedures – OPH tab template (oph_core_procedures), click the “Retinal Procedures” link to launch the Retina Office Procedures – Others – OPH template (retOfficeProcedure).

This template is where office procedures that do not involve the use of lasers are documented, including:



Cryopexy Gas-fluid exchange

Paracentesis

Pneumatic retinopexy

Documenting a Retinal Procedure (Non-Laser)

Workflow starts in the upper left of the template and flows down and across for each section.

1 Complete consent – Click the Consent Forms active text to open the Consent Forms – OPH pop-up (eyeConsentForms). This link is found in the upper right of the template in the Pre-Procedure Care section.

2 In the upper section of the template, complete the following by clicking in the field and selecting from picklists Category –.Click in field and select from picklist. Choices include: Macula, Retina, and

Vitreous/Periph. Diagnosis – Click in field and select from the Diagnosis Search dialog window that is

launched Anesthesia – Click in field and select from picklist Procedure – Click in field and select from picklist. To enter a procedure not listed, select the

top blank line and type using free text. Procedure choices include: Cryopexy, Gas-fluid exchange, Paracentesis, Pneumatic retinopexy.



Code – field is associated with procedure and will be populated automatically when a procedure is selected. If a procedure was manually entered, click in the field and manually type in the appropriate code.

Within 90 day PO period for same Tx and same eye – Click on the check box to select “No” or “Yes”

3 Pre-procedure care – Click on the check boxes to select appropriate items

4 Procedure Information

a) Goals – enter indication for procedure by clicking in the field and selecting from the picklist. To enter a value not listed, select the top blank line and manually type using free text. Select which eye the procedure will be performed on.

b) Eye – Select which eye the procedure will be performed on. If treatment eye has already been entered, it will be displayed here.

c) Surgeon – will automatically display the currently selected provider in the toolbar

d) Tech – Click in the field and select from your customized picklist of technician names, or close the list and type using free text.

5 The data grids at the bottom of the template for Best Visual Acuity, Vital Signs, Ocular History, Allergies, and Ocular Medications can be referred to as needed.

6 Preop IOP – Enter values for OD and OS, then click the Save button. If values for IOP have already been entered, they will be displayed here.

7 Mood/Affect – Click on the radio button to select “Normal” or “Abnormal”

8 Orientation – Click the radio button to select “Oriented x3” or “Abnormal”

9 Vital Signs – Double-click on the grid to launch the Vital Signs pop-up to document vital signs or click on the “Postop vitals waived by surgeon”

10 Patient Dilation – Click the Patient Dilation active text link to launch the Dilation/Other Medications – OPH pop-up template (ret_dilationpopup), where details about dilation are documented. Click Save & Close to exit the template.

11 Additional Procedure Notes - Add any additional information by clicking the “Additional Procedure Notes” active text to open the Retina Office Procedures Note – OPH pop-up template (retadditionalproc). Click in the large Note field and type any additional notes using free text. Click Save & Close, or click Cancel to exit without saving.

12 Procedure and details

a) Procedure - Click on a check box to select the appropriate treatment procedure(s) performed

Each of the procedures listed in the procedure picklist has a small section in the middle of the template where details can be documented.

b) Pneumatic retinopexy – Click on check box to select, and document the following:

Type of gas

Volume

Location

Paracentesis – select Yes or No; document Fluid removed volume in mL



c) Cryopexy – Click on check box to select, and document the following:

Location – select Superior, Temporal, Inferior, or Nasal

d) Paracentesis – Click on check box to select, and document the following:

Specimens sent to lab – select No or Yes

Fluid removed – select or enter volume in mL

e) Gas-fluid exchange – Click on check box to select, and document the following:

Type of gas – Click in field and select from picklist; enter value not listed by selecting the top blank line and typing free text

Volume – select or enter volume in mL

13 Notes - Add any additional information by clicking in the field and typing in free text.

14 Click the check box to select “Central retinal artery was examined and was well perfused after the procedure.”

15 No complications/Complications – Click on the “No complications”check box to select or document any complications in the adjacent field using free text.

16 Time of procedure – Click in the field and it will be automatically populated with the current system time.

17 Add to History – Click the Add to Histories button to add this procedure to the Ocular History grid. (History master)

18 Postop IOP – Enter values for OD and OS, then click the Save button. (Found below the Pre-op

IOP fields, in the middle of the template.)

19 Vital Signs – Double-click on the Vital Signs grid to launch the Vital Signs pop-up template to document post-operative vital signs, or click on the “Postop vitals waived by surgeon”.

20 Discharge Instructions – Click the Discharge Instructions active text to open the Discharge Instructions – OPH pop-up template (eyedischargeinstruct). Click on a check box to select an instruction document to generate. Click Save & Close to generate the document and exit the template.



Note: Only one Ophthalmology Instruction document can be generated per encounter.

21 Return visit

a) Photos today – Click the Schedule button to open the Task Tests – OPH pop-up template (eye_tasktests), where you can select and task various Ophthalmology procedures and tests. Click Save & Close to save and exit the template.

b) Future tests – Click the Schedule button to open the Task Future Tests – OPH pop-up template (eye_tasktestsfuture), where you can select and task various Ophthalmology procedures and tests to be performed in the future. Click Save & Close to save and exit the template.

c) RTC (Return to Clinic) – Click in the field and select from the picklist. To enter a value not listed, select the top blank link and manually type in using free text. Click the Save button below the RTC field.

22 Draw – Click the Draw button to launch a picklist of Ophthalmology drawing backgrounds. The Draw Module will open automatically. After documenting findings on drawings, click Save & Close.

23 When the procedure has been completed, click the Generate Note button found in the lower right corner of the template. This will generate a separate procedure note.

Retinal Diagnostics The Retina Diagnostics active text link on the Procedures – OPH tab template (oph_core_procedures) launches a 4-tab template set for Retinal Diagnostics.

The templates found in this tabbed template set are used in the following order:



1 Request Diagnostic Tests (retRequestDxTest) – used by the provider to schedule retina diagnostic tests

2 Perform Test (retPerformDxTest) – used by the technician to document that the test has been completed, and to inform the provider

3 DX Test Reports – used by the provider to review the results of all tests done during this encounter

4 DX Interpretation (retDxInterpretation) – used by the provider to document that the professional component of a diagnostic test (interpretation) has been completed

In addition, actual testing performed by the technician is completed on the Testing tab template (eyeOtherTests) of the Ophthalmology 10-tab office visit template set.

Request Diagnostic Tests When you select the Retinal Diagnostics active text link on the Procedures tab template, the Retina Diagnostics tabbed template set will launch open to the Request Diagnostic Tests tab (retRequestDxTest). Tests that were ordered by the provider will be displayed in the Test Scheduled Today data grid and in the Schedule Future Test grid.



Schedule Tests and Procedures

Click the Schedule button to launch the corresponding Task Test pop-up template used by the provider to schedule one or more tests and to task the technician with completing those tests.

Reference: Please refer to the section for Scheduling and Tasking Retina Testing and Procedures found earlier in this chapter.

Perform Diagnostic Tests The Perform Test tab of the Retina Diagnostics tabbed template set opens the Retina Perform Diagnostic Test – OPH tab template (retPerformDxTest). This template is used to document that Retina diagnostic testing has been completed. This template is generally used by the technician after they have completed the ordered test(s). Some tests are documented on the Testing tab template (retOtherTests) of the main Retina Ophthalmology 10-tab template set when they are being completed by the technician.

Documenting that a Test has been Performed

1 In the Ordered Diagnostic Tests grid, click on the row in the grid to select.



2 Information displayed in the grid will populate the edit fields found below the grid, including the Date scheduled, the person who requested the test (Requested by), the name of the test (Test type), and Test date. (If information had been entered for Location, Transit, and Study eye when the test was requested, this information will populate the corresponding edit fields.)

3 Click in the “Test Performed By” and “Test Time” fields located near the bottom of the template. Clicking in the fields will automatically cause the values to be assigned and displayed in the fields.

4 Notes and/or complications can be typed with free-text in the field at the bottom of the template.

5 Click the Save button.

6 Do this for each test request listed in the grid.

7 After a test has been completed, the Test Technician can notify the physician by Tasking.

8 (Optional) A report for the full Ophthalmology Exam can be generated by clicking the Generate Note button.

Interpretation of Diagnostic Test Results The DX Interpretation tab of the Retina Diagnostics tabbed template set opens the DX Interpretation – OPH tab template (retDxInterpretation). This template is used to document physician interpretation of findings for Retina diagnostic tests. This template is used by the provider after they have been notified by the testing technician that ordered tests have been completed.



Document an Interpretation of Test Results

1 In the Patients Tests grid, click on the row in the grid to select.

2 Click the “Interpret Test” active text found below the Patient Tests grid on the right to launch the Retinal Diagnostic Test Report – OPH template (retDxTestReport). (Seen as the DX Test Reports tab of this template set.)

3 Enter interpretation values for the selected diagnostic test by clicking in the fields and selecting from pick lists or clicking on check boxes.

4 Click OK to return to the Dx Interpretation tab template.

5 Additional information can be added by highlighting the test in the Patients Test grid, manually typing free text in the Interpretation and/or Notes fields, and clicking the Save button found below the Notes/complications field.

6 Repeat for each test listed in the grid.

There are two active text links found below the Patients Tests data grid, on the right:

1 DX Tests – All Test View Sheet – This link opens the Test Report – OPH template (rettestsummary) on which the results of Color Photos, FA, ICG, OCT, B-scan, and Microperimetry from multiple encounters can be viewed.

2 Interpret Test – This link opens the Retinal Diagnostic Test Report – OPH template (retDxTestReport).



This template is used to interpret the following tests: Color Photos, FA, ICG, OCT, B-Scan, and Microperimetry.

Highlight one of the appropriate tests listed in the Patients Test data grid and click the “Interpret Tests” active text link. After documenting an interpretation of findings, click Save & Close to return to the DX Interpretation template, or click Cancel to exit without saving.

Diagnostic Test Reports The DX Test Reports tab of the Retina Diagnostics tabbed template set opens the Retinal Diagnostic Test Report – OPH tab template (retDxTestReport). This template is where the provider’s interpretation of all Retina diagnostic tests done during this encounter can be viewed.

Retina Diagnostic Tests on the Testing Tab Some testing is performed by the technician and documented on the Testing - OPH template (eyeOtherExams), which is opened by clicking on the Testing tab of the main Ophthalmology 10-tab template set, or by clicking the Other Test link found in the sliding left side navigation pane.

While the details may vary depending on the tests being performed, when the technician receives a task to perform a test, this is the template where some of that testing is documented.



Documenting Testing and Results

1 Click on the check box corresponding to the test to select it.

2 For some tests, additional fields for documenting results may become visible.

3 Document results of testing, often by clicking in fields and selecting from picklists, or entering numeric values or free text.

4 Generate the Tech Report by clicking on the Tech Report button when you have completed the test.

5 Use Tasking to notify the provider that testing has been completed.

The following screen captures show the Testing tab template (eyeOtherExams).



A About This Guide • 9 Add or Update Assessments Template • 206 Advanced Directives • 84 Alerts • 70 Allergies • 120 Allergies (Brief) • 92 AMD Detail Exam • 184 Amsler Grid • 161 Assessment/Plan • 203 Assumptions • 10

B BDR (Background (Non-Proliferative) Diabetic

Retinopathy) Exam • 188 Blood Sugar • 147

C Cataract Post-Op Complications • 224 Clinical Problems Related to Ophthalmology •

52 Clinical Quality Measures (CQM) for

Ophthalmology in NextGen KBM • 43 CMS 143 (NQF 0086) - How to Document Optic

Nerve Evaluation for POAG Patients • 46 Coding • 225 Configuration Prerequisites for Retina Workflow

• 61 Configuring Default Templates • 18 Configuring Preferred Templates • 19 Consent Forms • 242 Copy Last Exam • 29 Correction • 83

D Default and Preferred Templates • 17 Demographic and Medical Information • 69 Diagnosis Categories • 52 Diagnosis Groups • 51 Diagnostic Test Reports • 259 Document a Plan • 214

Document Impression • 213 Documenting Autorefraction Findings • 156 Documenting Counseling Details • 231 Documenting Cycloplegic Rx and Dva Findings

• 158 Documenting Family Health History • 136 Documenting Lensometry Findings • 155 Documenting Manifest Refraction and Visual

Acuity Findings • 157 Documenting Medications in the Medications

Module • 113 Documenting Ocular History • 124 Documenting Ocular Procedures • 125 Documenting on the Family Health History

Template • 138 Documenting Past Medical History • 128 Documenting Past Surgical History • 130 Documenting the Management of Past Medical

History • 132 Drawings • 166

E Enter or Update Information on the Home - OPH

Template • 82 Exam Normal Findings • 38 External Exam • 163, 172

F Family History • 135 First Seen • 83

G General Patient Information • 96 Generate Chart Note • 235 Generate Note - History Summary • 148 Generate Progress Note • 105 Generate Tech Report • 167 Getting Started with Ophthalmology in NextGen

KBM • 23 Getting Started with the NextGen Ambulatory

EHR • 11 Gonioscopy Exam • 176

Index

Index


H Health Monitor • 88 Health Monitor (Summary) • 97 Health Monitor Intervals • 38 Histo (Presumed Ocular Histoplasmosis) Detail

Exam • 187

I Impression and Plan • 196 Impression and Plan Data • 48 Information and Links Found on the Patient

Information Bar • 68 Interim History • 134 Interpretation of Diagnostic Test Results • 257 Introduction • 9 IOP (Intraocular Pressure) • 91 IOP Exam • 162 IOP Measurements • 30

J Joint Commission Standards Standards

Configuration and Ophthalmology • 42

K Keratometry Exam • 160 Key Details about the Patient Information Bar •

68

L Launching the Ophthalmology Home Template •

53 Lensometry and Refraction • 154 Linking Tests/Procedures to Assessments • 229 Links to Other Templates • 72 Log In, Open a Patient Chart and Create a New

Encounter • 11

M Make VA Extended (Visual Acuity) and IOP

Extended Read Only • 35 Medical Decision Making • 230 Medication Reconciliation for a Patient • 116 Medications • 109

N Navigate to the CC-HPI-ROS Tab • 95 Navigation Buttons • 77

O Ocular History • 94, 123 Ocular Medications • 93 Ophthalmology - Better Visual Acuity within 90

Days of Cataract Surgery (CMS 133) • 44 Ophthalmology - Diabetes Eye Exam and

Communication with Physician for Diabetes Care (CMS 131 and CMS 142) • 45

Ophthalmology ASC Home Template • 55 Ophthalmology CC-HPI-ROS • 95 Ophthalmology Configuration on the

Ngkbm_Eyeconfig Practice Template • 23 Ophthalmology Drawing Module • 193 Ophthalmology Enhancements to Meet ICD-10

Standards • 46 Ophthalmology Home • 81 Ophthalmology Home Templates and Tabbed

Template Sets in NextGen KBM Version 8.3 • 55

Ophthalmology Patient Providers • 86 Ophthalmology Pre-Screening • 149 Ophthalmology Tech Exam • 151 Order Sets • 220

P Past Medical and Surgical History • 127 Patient Dilation and Other Medications (Eye

Drops) • 245 Patient Information Bar • 68 PDR (Proliferative Diabetic Retinopathy) Exam

• 190 Perform Diagnostic Tests • 256 Physician Internal Notes • 224 Plan Details • 217 Posterior Exam • 177 Print Chart Note • 30 Procedural Billing Grid Redesign • 46 Procedure/Test Billing • 228 Procedures - Workflow Shared Between

Providers and Technicians • 237 Procedures (Brief) • 195 Procedures Template • 237 Provider and Technician Signoff • 31 Provider Communications • 203 Provider Signoff - Exam • 171 Provider Start • 169 Provider Workflow • 169



Q Qualifiers for Clinical Content • 50 Quality Buttons and CQM Information Pop-Up

Templates for Ophthalmology • 43 Quick Plan • 215

R Request Diagnostic Tests • 255 Requirements • 10 Retina Diagnostic Tests on the Testing Tab • 259 Retina History of Present Illness (HPI) • 98 Retina Ophthalmology Basic Workflow Outline

• 67 Retina Ophthalmology Exam • 172 Retina Ophthalmology History • 107 Retina Ophthalmology Office Visit Workflow •

67 Retina Ophthalmology Workflow Basics • 61 Retina Ophthalmology Workflow Starting Point

• 63 Retinal Diagnostics • 254 Retinal Lasers • 247 Retinal Procedures (Other) • 250 Retinal Testing and Procedures Workflows • 238 Review of Systems (ROS) • 101 Review Patient Information on the Home

Template • 81 Review/Update Today's Assessments • 225 Revision History • 4

S Scheduling a Surgery in Ophthalmology • 198 Scheduling and Tasking Retinal Tests and Office

Procedures • 239 Select Today's Assessments • 205 Sig Filter for Eyeprescriptions (Ophthalmic

Medications) • 29 Slit Lamp Exam • 174 Social History • 142 Status Fields Added • 51 Submit Code • 232 Surgery Scheduling • 196 Systemic History • 126

T Tech Signoff - CC-HPI-ROS • 106 Tech Signoff - History • 149

Tech Signoff - Home • 94 Tech Signoff - Tech Exam • 167 Technician Workflow • 81 The Ophthalmology Home Template for General

and Retina • 56 The Ophthalmology Home Templates • 53 The Provider Specialty Grid • 27 Today's Assessment • 47

U Use Additional Visual Acuity Fields • 33 Use Military Time Format for Ophthalmology

ASC Time Fields • 36 Using the Exam Normal Findings Grid • 39

V Vascular Detail Exam • 191 Vision (Visual Acuity) • 89 Visual Acuity Exam • 153 Vitreomacular Detail Exam • 186

nextgen kbm ophthalmology retina user guide version 8.3

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