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, conjunctiva, cornea, iris, lens, discs, fundus, IOP, gonioscopy, 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
To record eye exam findings
- Access the Eye Exam Details screen.
For more information, see Selecting the Exam Set.
- 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.
- 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.
- Accept the default value or edit this field with your findings.
- In the OD description and OS description, click abnormal findings, if any.
- If you have additional findings to record, click the section of the exam for which you want to record findings.
- 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.
To record cup to disc ratio
- Access the Eye Exam screen.
For more information, see Selecting the Exam Set.
- Click the Discs section of the exam.
The Eye Exam - Discs screen opens.
- Make sure the check boxes for the exam description at the top of the screen are selected.
- In OD CD Ratio and OS CD Ratio, select the cup to disc ratio from the drop-down menu.
- In OD optic discs normal and OS optic discs normal, you can accept the default value or edit these fields with your findings
- In Lens Used, enter the name of the lens used for the exam.
- 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.