Entering Details for Common Plans on the iPad

1. On the Plans drawer, tap Bandage/Therapeutic Contact Lens.

   The Slit Lamp Eye diagram appears.

2. Tap the location of the impression on the Eye diagrams.

   You must select the location on the diagram before any details can be documented.

   The Details screen appears. The Glyph Slider may appear, which allows you to scale and rotate the location of the condition.

3. Select the Indication(s).

   To add more information, you can tap:

   • Medications if any post-operative medications will be administered.

     This tab is not used to prescribe medications. It is used for documentation purposes only.

   • Consent if you want to review the patient’s consent.
   • Post-care if you want to review or edit the patient's post-care instructions.
4. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap Contact Lens Assessment.

   The Details screen appears.

2. Enter the Price, if necessary.
3. Select a level for the Contact Lens Fitting Fee.

   You can enter a price of zero dollars.
   
   If you select a level, the level will be sent to your practice management system when you finalize charges.

   You can also tap any of the options below to enter additional information. All of these options are set to normal. You only need to record any abnormal findings.

   • Fit shows a list of possible fitting problems.
   • Comfort shows a list of comfort levels for the contact lenses.
   • Vision shows various problems with the clarity of vision provided by the contact lenses.
   • Lens shows various problems that may affect the contact lenses.
   • Ocular Health shows a list of ocular health problems that may affect the patient.
   • Other allows you to enter any other information regarding the contact lenses.
   • Plan allows you to select the plan as well as the lens and care recommendations.
   • Parameters shows a list of parameters that can be changed for the right and left eye.
   • Monovision allows you to select whether the contact lenses are monovision for the right and left eye.
   • Lens Counseling shows an Education Checklist from which you can select and document any counseling you gave to the patient.
4. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap Counseling.

   The Details screen appears.

2. Select whether you want full counseling or abridged counseling to appear in the visit note.

   Eyefinity EHR recommends using abridged counseling, which prevents large blocks of counseling text from being rendered in the note. This makes scrolling through exams easier and quicker. Full counseling is still rendered on anything patient-facing, such as patient handouts or the Patient Portal.

3. Select the check bubble for each Counseling Block you reviewed with the patient.
4. As needed, edit the counseling block with your counseling instructions.

   You can also tap these options for additional information:

   • Treatment Options displays Treatment Counseling Blocks that you can select for any information you discussed with the patient.
   • Decision allows you to document decisions you make related to the counseling.
5. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap Epilation.

   The Details screen appears.

2. Select the type of Procedure(s) performed.
3. Select the Location where the procedure was performed.
4. Select the Indication for Epilation.
5. Select the Anesthesia used.
6. Select any Complications, if applicable.

   You can also tap these options for additional information:

   • Forceps, Cryotherapy, and Electrosurgery allow you to review a description of the procedure note, the patient’s consent, and the post-care instructions, if the procedure was performed.
   • Laser allows you to review a description of the procedure note, the patient’s consent, and the post-care instructions, if a laser was used. You can also select the Laser Type, Spot Size, Power, Pulse Durations, and Total Shots.
   • Billing allows you to designate your CPT modifiers.
7. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap Extended Opthalmoscopy.

   The Details screen appears.

2. Select the Location where the ophthalmoscopy was performed.
3. Select the Status of the ophthalmoscopy.
4. Enter the reason why the ophthalmoscopy was a Medical Necessity.

   You can also tap these options for additional information:

   • Findings allows you to select any findings for the right and left eye.
   • Diagnosis allows you to select a diagnosis for the right and left eye.

     This tab is not used to diagnose the patient. It is used for documentation purposes only.

   • Assessment and Plan allows you to add comments to be included in the cover letter and to document the assessment and future plans for the right and left eye.
   • Billing allows you to select whether to bill as one line item or two line items if the opthalmoscopy was performed bilaterally.
5. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap External Photos.

   The Details screen appears.

2. Select the Location where the external photos were taken.
3. Enter whether there was any Other Indication.
4. Select the Reliability of the Study.

   You can also tap these options for additional information:

   • Findings shows a list of the potential findings for the right and left eye. The default is set to normal.
   • Diagnoses allows you to select diagnoses for the right and left eye. This tab is not used to diagnose the patient. It is used for documentation purposes only.
   • Assessment and Plan allows you to select the Assessment and Future Plans for the patient as well as record any Additional Notes.

     Some insurance plans will not reimburse for external photos assessed as baseline for future comparison.

     Tap the check bubble next to any procedures or treatments that could be performed for the patient in the future. Edit the descriptions of the plans, if necessary.

   • Billing allows you to select whether you'll bill the patient for the professional component, the technical component, or both.
5. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap F/U for Next Visit.

   The Details screen appears.

   Every impression has its own unique Follow-up plan.
   
   Do not use the Follow-up drawer in the Ocular Exam Room to create follow-up visits.

2. Select the Follow-up time Frame.

   The follow-up time frame will be sent to your practice management system when you finalize charges.

3. If you will treat the patient in some way during the follow-up visit, select the Planfor next visit as diagnostic or both.
4. (Optional) Enter the Protocols to be followed on the next visit for the right and left eye.
5. Tap the check bubble for each protocol to be followed on the next visit.

   On the side of the screen, additional options allow you to specify the exam, diagnostics, and procedures you want to perform for the patient’s next visit. Another option allows you to enter information for following up with another physician.

   • Exam allows you to tap the exams you want to perform for the patient on the next visit.
   • Diagnostics allows you to tap the diagnostics you want to perform for the patient on the next visit.
   • Procedures allows you to tap the procedures you want to perform for the patient on the next visit.
   • Laser allows you to tap the laser procedures you want to perform for the patient on the next visit.
   • Refractive allows you to tap the refractive procedures you want to perform for the patient on the next visit.
   • Follow up another DR allows you to select the follow-up time frame as well as enter the name of the physician to follow up with and any instructions for the patient.
6. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap the Fundus Photos plan.

   The Details screen appears.

2. Select the Fundus Photos Location as the right, left, or both eyes.
3. Enter any Other Indication.
4. Select the Reliability of study.

   One the side of the screen, additional options allow you to specify findings for various structures of the eye. All of these options are set to normal. You only need to record any abnormal findings.

   Other options allow you to select how the patient will be billed and to enter an assessment and plan.

   • Vitreous, ON, Vessels, Macula, and Periphery allow you to select the condition for the right and left eye.
   • Diagnoses allows you to select the diagnoses for the right and left eye.
   • Assessment and Plan allows you to select the Assessment and Future Plans for the patient as well as record any Additional Notes.

     Some insurance plans will not reimburse for external photos assessed as baseline for future comparison.

     Tap the check bubble next to any procedures or treatments that could be performed for the patient in the future. Edit the descriptions of the plans, if necessary.

   • Billing allows you to select whether you'll bill the patient for the professional component, the technical component, or both.
5. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap OTC Regimen.

   The Details screen shows a list of OTC regimens.

2. Tap the check bubble for the OTC regimens the patient will follow.
3. As needed, edit the description of the OTC regimen.
4. Tap Done to return to the Ocular Exam Room.

To use the Prescription plan

1. On the Plans drawer, tap Prescription.

   The Details screen shows a list of the medications you most commonly prescribe.

2. Select the medication you want to use or tap Add new Rx to search for a new medication.

   Do not prescribe over-the-counter medications on this window. This window is for therapeutic medications.

   Medication lists and dosages are updated monthly. If you're looking for a medication that isn't listed, check its status on the FDA National Drug Code Directory.

3. To see a history of the medications you have prescribed for the diagnosis, the medications other doctors in your practice have prescribed for the diagnosis, and what all doctors in the Eyefinity EHR network have prescribed for the diagnosis, tap Show Grand Rounds.
4. If the Drug Interaction(s) button is displayed, tap it to display a list of drug interactions based on the patient's medications and allergies.
5. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap Permanent Punctal Occlusion.

   The Details screen appears.

2. Select the Anesthesia used.
3. Select Complications, if any.

   On the side of the screen, the following additional options allow you to enter details about the procedure. You can also view the patient consent and view or edit the post-care instructions.

   • RUL, RLL, LUL, and LLL allows you to select the Punctal Occlusion Company, Punctal Occlusion Method, and Punctal Dilator as well as enter the Punctal Serial/Lot Number.
   • Laser allows you to select the Laser Type, Spot Size, Fluence, and Pulse Duration as well as enter the number of Total Shots.
   • Consent allows you to review a description of the patient’s consent.
   • Post-care allows you to review a description of the post-operative care instructions given to the patient.
   • Billing allows you to select the CPT Modifier, if any.
4. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap Reassurance.

   The Details screen appears.

2. Enter details for the plan.
3. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap Refraction.

   The Details screen appears.

2. Select the Location where the refraction was performed.
3. Enter the reason why the refraction was a Medical Necessity.
4. If you want to override your visit billing with an S-code, tap the option on the side of the screen.
5. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap Suture Removal.
2. On the Eye diagram, select the location of the sutures.

   You must select the location on the diagram before you can document any details.

   The Details screen appears.

3. Tap the check bubble in each text box for the instructions the patient will follow. Edit the descriptions of the instructions, if necessary.
4. Tap Done to return to the Ocular Exam Room.

1. On the Plans drawer, tap Treatment Regimen.

   The Details screen appears.

2. Select whether the Treatment Regimen is OTC, prescription, or both.
3. Enter the details for the Initial Regimen, if any.
4. Enter whether the patient is to Continue Regimen, Discontinue Regimen,or Modify Regimen.
5. Enter the details for the OTC Regimen, if any.
6. Enter the details for Samples Given, if any.
7. Enter any Other Instructions.
8. (Optional) Enter a Free Form description of the instructions for the Treatment Regimen Plan.
9. Tap Done to return to the Ocular Exam Room.