Begin the exam, then select past, family, and social history to open the documentation fields. The Vision(X) EHR will record data for any items for which "Yes" is selected. Selecting a "Yes" value for any listed item opens additional documentation fields for that item. For each sub-section of this menu (as listed on the left hand side of the screen), users can click "Mark all remaining as "No" to automatically mark any untouched item as "No". Each sub-section also includes a final field for general notes:
Patient Ocular History
A targeted record of the individual's past and present eye health. This portion of the exam includes sections for Extraocular Movements (EOM), Eyelids, Lacrimal, Pupils/Neuro/Orbit/Iris/Chamber, Sclera/Conjunctiva/Cornea, Lens, Optic Nerve/Visual Pathway, Macula, Vitreous/Retina/Choroid, Glaucoma, and Other Vision Conditions. Complete each section by continuously scrolling down:
Patient Ocular Surgical History
A targeted history of the patient's past surgical experiences. This portion of the exam includes sections for EOM/Orbit, Eyelids, Lacrimal, Cornea/Conjunctiva/Sclera, Lens/Iris/Chamber, Vitreous/Retina/Macula, and Glaucoma. Complete each section by continuously scrolling down:
Family Ocular History
A historical record of known eye diseases and other potentially-hereditary vision problems as documented in blood relatives of this patient. This portion of the exam includes sections for EOM/Eyelids/Lacrimal/Orbit, Cornea/Lens, Retina/Macula/Optic Nerve, Glaucoma, and "Other Problems." Complete each section by continuously scrolling down:
Family Ocular Surgical History
A historical record of eye operations and procedures performed on blood relatives of this patient. This portion of the exam includes sections for EOM/Eyelids/Tears/Orbit, Cornea/Lens, Retina/Macula, Glaucoma, and "Other Procedures." Complete each section by continuously scrolling down:
Patient Medical History
A record of key details related to patient's general health conditions. This portion of the exam includes Diabetes/Blood Sugar, Thyroid/Endocrine, Neurological, Dermatological, Muscle/Joint, Pulmonary, Cardiovascular/Hematology, Cancel, Genital/Urinary, Mental, Headache, Kidney/Liver, and Other conditions, as well as a field referencing Surgeries on non-eye parts of the body. Complete each section by continuously scrolling down:
Patient Allergies and Autoimmune History
A record of the patient's known allergies and autoimmune diseases/conditions. To add a new allergy, to this list, click "Record Allergy":
The "Record an Allergy" menu will appear. Select either Medication allergy/Other allergies toggle, then use the search field to select any/all allergens as appropriate, as well as their severity, current status, and patient reaction to the allergen. When finished, click "Confirm":
Complete each section by continuously scrolling down:
Family Medical History
A record of known allergies and autoimmune diseases/conditions in blood relatives of this patient. This portion of the exam includes sections for Diabetes/Thyroid/Endocrine, Allergies/Autoimmune, Neurological/Dermatological, Cardiovascular/Hematology, and Other conditions. Complete each section by continuously scrolling down:
Social History and Lifestyle
A record of general visual demands, environmental risks, personal habits, and current prescriptions needs of this patient as they may potentially relate to eye health. This portion of the exam includes Social History of alcohol and tobacco use, Lifestyle assessment of the patient's current prescription eyewear, Assessment of Regular Activities, Reading and Screen usage, Housing Status, and Race and Ethnicity. Complete each section by continuously scrolling down:
At the end of this portion of PFSH, double-scroll to continue to the next portion of the eye exam:
