Documenting Contact Lens Follow Ups in the Visit Overview (Web)

There are several ways that you can document a contact lens follow up in Encompass. Depending on your preference, you'll want to do one of the following:

  • Document the follow up using a previous diagnosis. This is the quickest method to document a contact lens follow up when the patient has come in for a visit.
  • Document the follow up using a new chief complaint. This is the most-detailed method for documenting a contact lens follow up when the patient has come in for a visit.
  • Document the follow up using a nonvisit order. If the patient has called in because they like their trials and want to order a supply, you can use this method to quickly finalize their trial Rx without creating a new visit.
What do you want to do?
  1. Open a patient visit. To learn how, go to Creating or Opening a Visit (Web).
  2. Document the follow-up complaint:
  3. Locate the CC/HPI|ROS section header, click the Add CC/HPI or ROS drop-down, and select Follow-up Complaint.

    1. Locate the diagnosis you're following up on and select the check box next to it.

    2. Click Save and Continue.

      3. A list of follow up questions appears.

    3. In the The patient presents for section, select Further Evaluation and Management.
    4. Answer any other questions as needed and click Continue.

      The follow up chief complaint is created.

  4. Document the contact lens prescription:
    1. Open a patient visit. To learn how, go to Creating or Opening a Visit (Web).
    2. Locate the Vision Summary section, click Add Tests, and select Contact Lenses for soft contact lenses, or tap Specialty Contact Lenses for RGP, scleral, or custom contact lenses.
    3. Click the Refraction History button.
    4. Click Import next to the prescription the patient is currently wearing.
    5. Under Status, select Dispensed Successful or Dispensed Unsuccessful depending on whether or not the trial lens was successful for the patient.
    6. Click Save.

  5. If the lens was successful for the patient, click the Create Final Rx link on the trial lens.

    If the lens was unsuccessful, click the Contact Lens tab and document the next trial lens the patient will be trying out.

  6. Click Finalize Visit.
  1. Open a patient visit. To learn how, go to Creating or Opening a Visit (Web).
  2. Document the follow-up complaint:
  3. Locate the CC/HPI|ROS section header, tap the Add CC/HPI or ROS drop-down, and select Chief Complaint.
    1. Select Contact Lens Detailed from the list of complaints.

      The chief complaint details screen opens.

    2. On the Is this a new presentation, or a follow-up? tab, select the Follow Up Contact Lens Evaluation option.
    3. Answer any additional questions as needed and tap Save.

      The follow-up chief complaint is created.

  4. Document the contact lens prescription:
    1. Open a patient visit. To learn how, go to Creating or Opening a Visit (Web).
    2. Locate the Vision Summary section, click Add Tests, and select Contact Lenses for soft contact lenses, or tap Specialty Contact Lenses for RGP, scleral, or custom contact lenses.
    3. Click the Refraction History button.
    4. Click Import next to the prescription the patient is currently wearing.
    5. Under Status, select Dispensed Successful or Dispensed Unsuccessful depending on whether or not the trial lens was successful for the patient.
    6. Click Save.

  5. If the lens was successful for the patient, click Create Final Rx on the trial lens.

    If the lens was unsuccessful, open the Contact Lens tab and document the next trial lens the patient will be trying out.

  6. ClickFinalize Visit on the upper right side of the screen.
  1. Create a new nonvisit order. To learn how, go to Creating a Nonvisit Order (Web).
  2. Add free-text note describing the nature of the order:
    1. Locate the Note section and type your notes, which save automatically.
  3. Document the trial contact lens prescription:
    1. Select Glasses & Contacts from the Action bar.
    2. Click the Trials tab.
    3. Click New Trial Soft Contacts for soft contact lenses, or click New Trial Specialty Contacts for RGP, scleral, or custom contact lenses.
    4. Click the Refraction History button.
    5. Click Import next to the prescription the patient is currently wearing.
    6. Under Status, select Dispensed Successful or Dispensed Unsuccessful depending on whether or not the trial lens was successful for the patient.
    7. Click Save.
  4. Click the Finalize Order button.
  5. Click Finalize Note to confirm.