Finalizing EMRs

When you finalize an exam (EMR), an alert can prompt you to take an action if the exam meets a condition (Clinical Decision Support or CDS rule). For information on how to set patient alerts, see Creating Clinical Decision Support Rules and Patient Alerts.

This topic describes how

You must click the Coding icon in ExamWRITER, verify or add diagnosis and procedure codes on the Diagnosis/Procedure Coding window, and click Save/Exit before ExamWRITER will allow you to finalize an exam. If you have automatically recorded procedure codes in the exam, but the “Coding is Incomplete, Click Continue to Code Exam.” message appears, then you have not saved the codes in the Diagnosis/Procedure Coding window and you must do so before finalizing the exam. For more information on verifying and adding diagnosis and procedure codes in exams, go to Selecting the Codes.

You cannot close or finalize any exams that were copied forward that contain items in blue text. The blue text indicates that you copied ICD-9 codes forward and there was no exact correlation between those codes and their ICD-10 counterparts. You must remove the items in blue text in the exam and reselect them using ICD-10 codes.
  1. Click the Finalize icon in the top left of the ExamWRITER chart window.

    The Exam Finalization window opens.

  2. If the Exam Review indicates that the coding is incomplete, click Continue; otherwise, select the Activities that you want to perform:
    • Select Print Exam to print the exam.
    • Select Print Spectacle Rx to print the spectacle Rx.
    • Select Print Contact Rx to print the contact lens Rx.
    • Select Print Patient Report [MU] to print the eyecare report.
    • Select Exam is Billable/Reportable [MU] if the exam is billable and should be documented as a reportable exam for meaningful use measures.
      Deselect Exam is Billable/Reportable [MU] if you are creating an exam record for a phone call, desk chart, contact lens follow-up, etc., so that the patient notes are not documented as an office visit/patient encounter for meaningful use measures.
    • Select Print Auto Letter [MU, QRM] to print the auto letter.
    • Select Print Alternate Spectacle Rx to print the alternate spectacle Rx.
    • Select Print Trial Contact Rx to print the trial contact lens Rx.
    • Select Print Clinical Summary [MU] to print the clinical summary that contains information from the Patient Report and clinical summary CCR
    • Select Create No Med/No Allergy entry [MU] if the patient does not have any medication or medication allergies and you did not click the No SYSTEMIC Medications [MU] and No Medication Allergies [MU] buttons on the Patient SYSTEMIC Medications and allergies [MU] window.

    Recording billable exams and printing auto patient reports, auto letters, and clinical summaries helps your practice meet meaningful use criteria. To better understand meaningful use and its criteria, see http://www.cms.gov/EHRIncentivePrograms/.

    If the Assessment/Plan and Patient Management sections of the EMR are incomplete, a yellow warning message appears; however, you will not be prevented from finalizing and closing the EMR.

    For more information on selecting Activities, go to To set up general preferences. For more information on coding, go to Selecting Diagnosis and Procedure Codes.

  3. Select the CLOSE record or FINALIZE record radio button.
    If you choose to close the record, you will be able to open the record at a later time and review it and make changes. Note that you can update exam coding selections (for services only) in closed exams. If the fee slip for the updated exam has not been recorded in OfficeMate, the line item(s) on the fee slip will be updated. If the fee slip for the updated exam has already been recorded in OfficeMate, the fee slip will not be updated. Closing exam records gives you the ability to review the record at the end of the day before you finalize it.

    If you choose to finalize the record, you will be able to open the record at a later time, but you will not be permitted to make changes. You will only be able to make additions and changes to the EMR in an addendum. For information on adding addendums, go to Adding Addendums to EMRs.
  4. Select the provider signing off on the exam from the Sign-off Provider drop-down menu.
  5. If this is a VSP exam, select the appropriate VSP EHM check boxes to participate in the Eye Health Management program.
    The VSP EHM check boxes may already be selected based on the findings recorded in the exam or from the patient’s history.

    The EHM information, associated diagnosis codes, and dilation information are sent when the claim and order are transmitted to VSP.

  6. Click Save/Exit.
  1. Click the Chart Search tab on the ExamWRITER Control Center window.
  2. Search for a group of exams to finalize:
    1. Choose a date range for your search from the date From and to boxes.
    2. Select an exam status from the Status drop-down menu.
    3. Select a provider from the Provider drop-down menu.
    4. Click Search.
  3. Click Finalize.

    The Confirm window opens.

  4. Click Yes to finalize all of the closed exams that are displayed

In addition to the procedures in this topic, watch this video.