How do I add an Exam and complete the EMR (EHR)?
Most doctors start from a template in the EXAM window. Enter the patient number from the top of their form
1. "Home" > Exam 2. Choose a template
An exam can also begin in the PATIENT Window (click on "Create Exam" on the left)
Enter the patient number
Exam Window in short view, default for patients with no previous exams
An Exam can also begin in the Exam Window. Click the "+" to begin a new exam (red circle).
Quick Highlights of this window:
1. Diagnosis options. The default tab is for routine exams. There is also a tab for Medical or Surgery exams, Forms and Dr/Setup.
2. Chief complaint, HPI, family and medical history, allergies, meds, and more will all be populated automatically in the EXAM from the entrance form. You may edit anything wherever you see it.
3. Today's patient list (from the Calendar). Click the blue detail button to go to that exam. The "Y" on the right means the chart has been signed (automatic when billed).
4. Habitual glasses (pulled from previous visit or the Patient Window). The small grey buttons enter common values like the "+Habitual" button (green arrow) pulls the habitual into the refraction.
Many offices have a pre-tester enter values in the fields above the green arrow.
Edit Medical History, Family History, Eye wear History, Review of Systems, and Doctor History (refresh from entrance forms)
1.Click "Forms" to edit the entrance forms or "Refresh" to pull changes from the entrance forms.
2. Just click and modify the history (without updating the entrance form info)
3. Click "Edit List" to edit the Medical and Family history items only (below)
Edit Past Medical and Family History List
1. Add to the Family OR Medical history
2. When you look at an old EXAM notice that items with a grey background will be included since they were recorded before the EXAM date, you may modify the dates if they are incorrect.
3. Click "Refresh" to pull any changes into the Exam
Exam Window in detailed view, default for patients with exam history
Bottom portion of Exam Window
1. Click the "down arrow + button" for a pop-up window to quickly enter plus lenses.
2. Click "Dilate" to record time and drops.
3. Click "+ Marco" to pull in digital lensometry, autorefraction, "K", refraction, VA's and some binocular test results (requires setup).
4. "+Drop" or "+Path" to grab digital photos, scans, PDF files, and more. Will also prompt you to enter a "separate intrepretation and report" if you are billing for the test (requires setup).
5. Edit the patent's plan by typing in the box or click "Plan (boxes)" for a set of check boxes and add your own comments. "Plan (add)" is to APPEND a note to this exam at a later time.
6. "Recall reason" is used to send a recall letter about that diagnosis instead of a post card.
7. "+Report" is used to create a report for the patient about the diagnosis (can be created as a password protected PDF that contains images and web links).
8. Reminder that you may be able to bill for additional testing for this diagnosis (E= Extended opthlamoscopy V=Visual Fields P= Posterior Photos G= Gonioscopy
A= Anterior Photos S= Laser opthlamoscopy Q=PQRI).
9) "Edit defaults" to edit acronyms for abnormal findings. Add them from the drop down list then click "OD", "OS", or "OU" to record the finding to "Anterior" and/or "Posterior" field(s). Customize other value lists by clicking "Edit" at the bottom of the list.
To Rx contacts, click the "Contact Lenses" tab
1. Habitual CL will show up in the first row (in blue, not shown in this example) and "Habitual" will be checked.
2. Vertexed actual and rounded to .25.
3. "Pwr" will guess at the power (click the lens type first) by calculating the vertex, rounding cyl to .75, 1.25, 1.75, or 2.25, and rounded axis to the nearist 10.
4. Arrows push text to another box so you don't have to type. Bigger arrows push from OD to OS, smaller push down one line.
5. "Trial" adds the word "trial" to the Rx so staff knows the Rx is not "final."
6. "Rx" pulls that lens to "Rx Today" (your final or trial CL Rx)
7. All previous CL findings listed in a new window.
8. Slit lamp findings (uses type ahead).
9. "Finalized" happens when you bill, automatically, but is shown here in case you want to edit it. You can also add "Rx 2" (drag and drop).
10. "T" for trial, will list the lens and let you quickly print a page so your staff can find the trial and and have your patient put it in.
1. Add Drug Rx.
2. "+Plan" adds the drug to the plan (automatic if you print the Rx).
3. Edit your drug list or preferences.
4. E-Prescribe interface (requires setup).
5. Other less common test results.
7. History of reports. Reports are dated and saved (most recent one first).
8. Modified Final Rx is shown here only if it is different than the refraction.
Lower Right portion of Exam Window
2. The "Customize Final Rx" is for when your prescription is different from the exam findings. If you use this function during the exam and then need to make a change, click this button again to update the information.
3. The "Coding" button is a help feature for figuring out which code to use.
4. The chart is signed when you enter a billing code. If there is no billing code, you can click "Sign" to finish with the exam. This may be useful in a follow up visit where there is no charge.
1. Import an image let's you specify an image or file
2. "+ jpg" or "+ PDF" grabs the file from a consistent file path
3. Add a drawing (pc only)
4. Interpretation and report
To enlarge the image double click it
Here is a 2 min video on IMAGES