Begin the exam, then select the Ocular Health category to open the documentation fields. If this portion of the exam has already been documented by another provider, or will simply not be performed as part of today's exam, select the check boxes as appropriate:
Diagnostic Pharmaceuticals and Dilation
Select the "Physical Evaluation" toggle. If any pharmaceutical products will be used as part of this exam, click "Add/Edit":
A documentation window will open from the right-hand side of the screen. Use the drop-down menus to document pharmaceuticals as appropriate, then click to close:
If dilation is to be performed in this exam, select the "Yes" toggle, then add a time to the required field:
If dilation is not to be performed in this exam, select the "No" toggle, as well as a selection from the required "Reason" field:
For each field, begin by selecting an option from the "Normal Y/N" toggle. Findings can be entered manually into each free text field, or general finding notes can be added for each normal field by clicking "Fill form with condition" and selecting an option, then editing the notes as appropriate. All fields can be reset quickly by clicking the "Clear All" button.
To document any non-normal finding, mark the finding with the X, then click to open the Link ICD menu:
The Link ICD menu will appear from the right-hand side of the screen. Use the search field to select an ICD code, then document as appropriate. Lastly, select an option to document this as either a "Diagnosis" or a "Finding." Marking as a diagnosis will add the ICD code as a billable item for this exam, while marking as finding will only log the item as part of the exam without an additional billing. Close the menu when finished:
The Diagnosis/Finding has now been saved. If you possess clinical images that you would like to attach to this field, click "Open Image Module":
The Clinical Images menu will appear as a pull-out from the right-hand side of the screen. Click "Manual Upload" to add any image file, then click the "X" to close the menu when ready:
Anterior Segment
Continue to the Anterior Segment documentation fields, and complete as appropriate:
Optic Nerves/Visual Pathway
Continue to the Optic Nerves/Visual Pathway documentation fields, and complete as appropriate:
Continue to the Fundus documentation fields, and complete as appropriate:
Use the toggles to indicate functional and cognitive statuses. If "No" is selected for any option, an option to link SNOMED CT-11 code will appear:
Other Tests
If additional tests are to be performed as part of documenting ocular health, select "Other Tests" from the toggle near the top of this exam section:
All additional tests in this portion of Ocular Health are considered optional, and only test results that are actively have values entered by the user will be recorded for this section of the exam:
When ready, double-scroll the bottom of the page to proceed to the next portion of the exam:
