Documenting Gonioscopy on the iPad

You can document gonioscopy within the Ocular Exam Room. Eyefinity EHR enables you to record your evaluation in several different ways.

  • To record your overall findings, use the Gonio section of the Eye Exam.
  • To visually record findings, select Gonioscopy Drawing under Glyphs. For more information on using glyphs, see Creating Glyphs on the iPad.

  • To record that gonioscopy was performed in relation to a specific diagnosis, select the Gonioscopy plan.

    If you're billing for gonioscopy, make sure to select Gonioscopy as a plan. This is what generates a billing code. Simply documenting findings under the Gonio tab of the Eye Exam or applying glyphs will not generate a gonioscopy billing code.

This topic covers how

  1. Open the Ocular Exam Room.
  2. Tap the Exam drawer to open it.
  3. Tap Perform Exam.
  4. Select Eye Exam from the list of exam sets.

  5. Locate the Gonio tab in the list of tabs along the side of the screen and tap it.

    You may need to scroll down the list of tabs before Gonio is visible. To scroll, swipe up on the list of tabs.

  6. Select the check bubble for gonioscopy.
  7. Record your findings.

  8. Click Done.

    Your findings are added to the visit note. If you're done documenting in the Ocular Exam Room, make sure to tap Save Visit Note.

  1. Open the Ocular Exam Room.
  2. Tap Glyph Tools.

  3. Tap Gonioscopy Drawing.

    A list of glyphs appears in the Plans section.

  4. Select the glyph you want to record.
  5. Tap the location on the eye diagram where you want to apply the glyph.

  6. Use the Rotate and Scale options to modify the appearance of the glyph.

    To continue placing glyphs, repeat Steps 4-6.

    When you select glyphs, Eyefinity EHR backfills any normal findings you previously recorded as a part of the Eye Exam. You can check what was added to the visit note by tapping Quick Impression Edit and then tapping the Exam Details tab. If you're done documenting in the Ocular Exam Room, make sure to tap Save Visit Note.

  1. Open the Ocular Exam Room.
  2. Select a diagnosis.
  3. Indicate the location of the diagnosis by tapping the eye diagram.
  4. Indicate the status of the diagnosis by tapping Status or New Dx.
  5. Record any findings as necessary.
  6. Select the Gonioscopy plan.
  7. Indicate the Location and Reliability of study.
  8. Record additional notes in the Medical Necessity box if gonioscopy was medically necessary.
  9. Tap the Assessment and Plan tab.
  10. Indicate your Assessment using the drop-down list.

  11. Select the check bubble for any evaluation or treatment option that applies.

    Your selections will be remembered and will default in the future whenever you select the Gonioscopy plan.

  12. Tap Done.

  13. Record any other plans as necessary.

  14. Tap Save Visit Note.

    The billing code for gonioscopy appears in the coding section of the Visit Overview.