Recording Findings in the Eye Exam

Tabs are displayed along the top of the Eye Exam Details screen showing the various sections of the eye exam. The default exam set includes findings for external eyes, conjunctivaClosed Mucous membrane that lines the visible part of the eye and the inner surface of the eyelid. If the conjunctiva becomes red, the condition may become conjunctivitis., corneaClosed The clear part of the eye covering the iris and pupil; it lets light into the eye, permitting sight., irisClosed Colored part of the eye. The iris has muscles that allow it to change the diameter of the opening in the eye (pupil). These muscles regulate the amount of light in the eye., lens, discsClosed The point at which the optic nerve connects to the retina., fundusClosed Tissues at the back of the eye, or retina., IOPClosed Intraocular Pressure. Eye pressure, as determined by the amount of aqueous humor filling it. High IOP (ocular hypertension) can be a sign of glaucoma., gonioscopyClosed Technique that uses a special lens and slit lamp to view the inner angle of the eye., miscellaneous, and skin. When you initially access the eye exam, all sections of the default exam set are set to normal. This saves you time because you only have to record abnormal findings.

You can document your findings in the Eye Exam Details screen, or you can document your findings by using diagnoses, findings, and plans in the Ocular Exam Room. If you document your findings in both places, your findings are duplicated in your visit note.

This section explains how

  1. Access the Eye Exam Details screen.

    For more information, see Selecting the Exam Set.

  2. At the top of the screen, click the section of the exam for which you want to record your findings.

    The Eye Exam Details screen for that section opens.

  3. If you are performing this section of the exam, make sure the check box for the exam description is selected.

    If you are not performing this section of the exam, clear the check box for the exam description.

    The description for the right and left eye is pre-populated with a description of normal findings.

  4. Accept the default value or edit this field with your findings.
  5. In the OD description and OS description, click abnormal findings, if any.
  6. If you have additional findings to record, click the section of the exam for which you want to record findings.
  7. When you have finished recording findings, click Done with Exam.

    If you made an error in recording your findings and want to start over with a blank exam set, click Reset Exam.

  1. Access the Eye Exam screen.

    For more information, see Selecting the Exam Set.

  2. Click the Discs section of the exam.

    The Eye Exam - Discs screen opens.

  3. Make sure the check boxes for the exam description at the top of the screen are selected.
  4. In OD CD Ratio and OS CD Ratio, select the cup to disc ratio from the drop-down menu.
  5. In OD optic discs normal and OS optic discs normal, you can accept the default value or edit these fields with your findings
  6. In Lens Used, enter the name of the lens used for the exam.
  7. When you have finished recording findings, click Done with Exam.

    If you made an error in recording your findings and want to start over with a blank exam set, click Reset Exam.