Documenting Cataract Postoperative Care on the iPad

Eyefinity EHR enables you to document a visit for a patient who is coming in after cataract surgery. This topic provides an overview of how

To document a cataract postoperative visit on the iPad

  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 dilated 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 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 OD, OS, and OU. For information on creating protocols, go to Working With Protocols.