Documenting Cataract Postoperative Care in the iPad App

Encompass enables you to document a visit for a patient who is coming in after cataractClosed Clouding of the natural lens of the eye, usually caused by aging in conjunction with such risk factors as exposure to the sun's UV rays, smoking, steroid intake, and diabetes. Symptoms include blurred vision, glare, halos around lights, colors that are less bright, a cloudy spot in vision, and temporary vision improvement. surgery. This topic provides an overview of how

To document a cataract postoperative visit in the iPad App

  1. Create a new visit for the patient.
  2. Tap the CC/ROS button on the action bar.
  3. Tap Add Chief Complaint.

  4. Search for and select Postop Cataract.

  5. Indicate which eyes the cataract surgery was performed on using the eye diagram.

  6. Tap Complaint Details.

    Alternatively, you can follow up on a past diagnosis by selecting it from the Follow-ups section and tapping Save.

  7. Under Is this a new presentation, or a follow-up?, select the check bubble for Follow Up Postop Surgery.
  8. Record additional information as needed.

  9. Tap Save Complaint.

  10. Complete the Review of Systems and Vision Exam section as necessary depending on your examination.
  11. Save your work and tap the Exam button on the action bar.
  12. Document the Eye Exam, making sure to indicate whether or not you dilatedClosed To expand the pupil of the eye. Pupils are most commonly dilated during the internal exam. Occasionally pupils are dilated in disease cases as a means of preventing the iris from sticking to the lens of the eye. the patient.
  13. Select the cataract diagnosis you are following up on.

  14. Under Findings, type "Clear and Centered PCIOL" into the search bar.

  15. Tap Add Custom Finding.
  16. Under Finding Relates to, select sle lens.
  17. Toggle the Always remember this finding option to the "ON" position.
  18. Tap Done.

  19. Document the following plans:

    • Post Op Evaluation Cataract. This plan will add a 99024 CPT codeClosed Current Procedural Terminology. The numeric codes that are submitted to insurers for payment. Every billable procedure has its own individual CPT code. to the visit. If you don't want this code to generate, select No from the drop-down list. Also, make sure to select the Location as well as the Postop Day OD and Postop Day OS to meet Quality requirements.
    • Comanagement. Specify the Operated Eye?, and under Relinquish/Assumption of Care, select Assuming Care. You can also modify the Comanagement CPT Code from here.
    • Set Global Period. Select the Location, select the type of surgery from the Surgery Picklist, set the Other surgery global period to 90, and enter the Date of Surgery.

    • F/U for Next Visit Cataract. Set the follow up details.

      For all subsequent visits, you only need to use the Postop Cataract diagnosis and the Post Op Evaluation Cataract plan, where you can enter all the details of your evaluation. Comanagement and Set Global Period only need to be applied to the initial "Day 1" visit.

  20. Tap Save Visit Note.

  21. Tap Finalize Visit, and confirm your finalization.

    Due to the amount of steps required to document a postoperative visit, it's recommended to create protocols to save you time. You might create a protocol for "Day 1 Postop Cataract", "Week 1 Postop Cataract", and so forth for ODClosed Oculo Dextra. Latin abbreviation for right eye., OSClosed Oculo Sinestra. Latin abbreviation for left eye., and OUClosed Oculo Uterque. Latin abbreviation for both eyes.. For information on creating protocols, go to Working With Protocols.