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R8 Phys/Scribe Work View Guide Contents
Open Patient’s Chart Note ....................................................................................................................................... 4
Other areas of the work view- ............................................................................................................................. 6
Patient at a Glance ............................................................................................................................................... 7
Common changes: ................................................................................................................................................ 8
DOS-.................................................................................................................................................................. 11
Visit Type- ......................................................................................................................................................... 11
Template-.......................................................................................................................................................... 11
CC & History- ................................................................................................................................................... 12
User Logged In- ............................................................................................................................................... 12
Neuro/Psych- ................................................................................................................................................... 13
AD (Advance Directive)- ................................................................................................................................. 13
Other Chart Note Fields: ................................................................................................................................ 14
Assessment and Plans ....................................................................................................................................... 14
Follow up .............................................................................................................................................................. 19
Toolbar Icons ........................................................................................................................................................... 21
Test Manager....................................................................................................................................................... 21
eRx ........................................................................................................................................................................ 22
General Health .................................................................................................................................................... 22
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Smart Charting .................................................................................................................................................... 23
Pt. Communication ............................................................................................................................................. 24
Pt. Instruction Documents ................................................................................................................................. 25
Allergies- ........................................................................................................................................................... 25
Surgeries .............................................................................................................................................................. 25
Flow Sheets ......................................................................................................................................................... 26
Patient Refractive Sheet .................................................................................................................................... 26
Print Patient Summary ....................................................................................................................................... 27
MUR Checklist ..................................................................................................................................................... 28
Chart Note Sidebar ................................................................................................................................................. 29
Patient Instruction ............................................................................................................................................... 34
Patient Forms ...................................................................................................................................................... 34
Closing a patient’s chart ..................................................................................................................................... 35
Chief Complaint ....................................................................................................................................................... 35
Entering a chief complaint ................................................................................................................................. 37
Vision Exam ............................................................................................................................................................. 38
Distance and Near Vision (AR and K) ............................................................................................................. 39
Present Correction .............................................................................................................................................. 40
Manifest Refractions (plus GL and PH) ........................................................................................................... 40
Cycloplegic ........................................................................................................................................................... 41
Contact Lenses ................................................................................................................................................... 41
Contact Lens Worksheet ................................................................................................................................ 42
Confrontational Vision Fields, Amsler Grid, and others ............................................................................ 45
ICP Color Plate and Stereopsis .................................................................................................................... 46
Summary Examination Chart......................................................................................................................... 46
Drawing Tool .................................................................................................................................................... 50
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Gray and White Field Backgrounds .............................................................................................................. 51
The Examinations ............................................................................................................................................ 51
Main Sections of the Summary Examination Chart ....................................................................................... 52
Pupil ................................................................................................................................................................... 53
EOM (Extra ocular movements) & Other examinations ............................................................................ 54
External ............................................................................................................................................................. 54
Lids & Adnexa .................................................................................................................................................. 55
IOP/Gonio ......................................................................................................................................................... 57
Physician Notes ................................................................................................................................................... 58
Patient Information .......................................................................................................................................... 59
Edit Patient Information .................................................................................................................................. 60
Display Patient’s Demographic History ........................................................................................................ 60
Change Language, Ethnicity, Race and Occupation ................................................................................. 61
Consent Forms ................................................................................................................................................ 61
Taking the Patient’s Medical History ............................................................................................................ 61
Procedures ........................................................................................................................................................... 62
Tests ......................................................................................................................................................................... 63
IMedicMonitor .................................................................................................................................................. 65
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Introduction
Work View – Assessments, Vision Examination, and Tests
After taking the patient’s medical history, the technician must carry out the assessments and
tests required by the physicians. This is done at the Work View screen. Click [WORK VIEW] to
start.
Open Patient’s Chart Note
When the user first selects a new patient’s chart in Work View, they’ll see a pop-up noting they
are opening the first chart of “patient name – patient ID.”
Active chart note warning
Click [OK] to continue or [CANCEL] to abandon the operation. Today’s date is shown in the
DOS field at the top of the chart. The default template is comprehensive, but this can be
changed during the assessment. The system will automatically open a new chart note based on
either the Comprehensive template (all facilities), or the doctor’s preferred template.
There are three reasons for this:
1. Once a Chart Note is opened, it must be finalized by a physician. If the patient is not
worked up, the doctor will be signing off on a blank Chart Note.
2. The system carries information from a previous Chart Note. If a previous Chart Note is
not finalized, its information will not be carried forward.
3. The system will not allow two active Chart Notes to be open at the same time. When
starting, the Chart Note opens to the previous DOS. The technician may not notice, resulting in
data with the wrong date of service. When a Chart Note is first opened, the patient medical
history is displayed, so the technician and physician can review all aspects of the patient’s
previous visits and health. Click [Reviewed] to continue.
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Patient Search Visits Search Dates Switch Users Scheduler
Workview chart
1. The patient’s name and e/Rx indicator are displayed toward the top-middle of the screen.
The bar above shows:
• The type of examination
• Insurance case – medical, auto, worker's comp etc.
• Insurance company (click for more information such as the policy number)
• Displays details of physicians, which can be viewed, entered, and updated.
Referring Physicians (RP)
Primary Care Physician (PCP)
Co-Managed Physicians (CM)
2. Chief Complaint
3. Patient history
4. Ocular medications
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Other areas of the work view-
• Vision Examination Displays areas of the main vision examination. Click arrows to
display, click again to hide.
The first bar is automatically expanded; subsequent bars are expanded when they contain data.
The five vision bars are used as follows:
● Distance, Near vision, Auto refractor, Auto keratometer
● PC (Present corrections) for up to three pairs of glasses
● MR (Manifest refractions), again up to 3
● Contact Lens worksheet
● Confrontational Fields, Amsler Grid, and other tests
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• Summary Examination Chart- here the technician will see the details of any
conditions. These sections range from the outer to the innermost parts of the eye, from
the outer regions of the orbit to the fundus.
Patient at a Glance
Clicking this icon displays the patient’s active problem list, medications and assessments/plans
from previous visits, and other important information. This is a quick way for a provider to glean
an overview of a patient’s health and medical history.
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Patient at a glance
The dates of patient visits are listed below, and are hyperlinked. Clicking them will bring you to
the chart for that date’s visit.
Previous patient visits
Common changes:
● Chief Complaint--To see the last chief complaint click [CC & HISTORY] or within the
Medical History module review the Chief Complaint and Problems tabs. Both screens
are populated with information entered during previous examinations. A new Chief
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Complaint must be entered for every visit but for a follow up visit this can be as simple
as be a minor complaint selected from HPI, such as a glaucoma follow up.
● Vision Examination-- If the vision examination results are the same click in the results
fields so that they are no longer grey but do not enter any further information. If there is
a change, click the results fields and enter the change(s). If the user does not do
anything (e.g. take the keratometer readings) leave them grey, indicating that this action
was not taken this time around.
● Chart sections-- where there are no changes. At these sections, hit [NC]. NC will carry
over unchanged information from the previous chart for the current examination section.
● Findings that no longer apply-- If there are sections of the chart (that were previously
selected) that no longer apply (e.g. blepharitis on lids has cleared up) then uncheck the
indications. Then, hit [NC] indicating no further changes.
● Assessments-- If a previous assessment no longer applies to this visit check RES
(resolved). The item will be billed for this visit but will not be carried over to a future
chart.
● Plans--Previous plans (for a previous visit) can be listed by clicking [PREVIOUS
PLANS}. A list is displayed. If plans are largely the same the technician can review the
previous one and, if required, make any changes.
● Super Bill--all grey items in the patient’s chart will not be considered for super bill
purposes.
● Implications for printing the patient’s chart
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Chart Note
All grey items are ignored by the patient chart print function. If the technician prints the patient
chart without entering a field to show it has been examined during the current visit, the system
will show nothing to be printed. If a printed patient chart is blank (contains no detail), this is likely
because during the current visit the clinician may not have done everything that was performed
during a previous visit.
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DOS-
The date of service is set to today’s date. If you previously opened the chart but did not
complete it, you will need to update the date of service.
Date of service
Visit Type-
This is usually filled out by the system’s appointment function, when an appointment is created
by the Front Desk. The type of visit determines the template of the displayed work view fields.
Visit type drop-down
Template-
Please note that the left slider has been removed in R8. To create a new chart, the user must
select a Template from the first drop down in the green bar at the top left of the screen.
If a different type of template is selected from the drop down, the screen will change. The
“reasons for the visit” templates are set up in Admin. These are doctors’ specific templates and
can be changed by the technician or physician at any time without loss of data--for example, if a
patient is seen for a post-op and during the examination the technician notices a new condition
unrelated to the post-op.
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Template drop down
Quick Tip: The current template does not include the portion of the chart needed to document
this new condition (for example, an eyelid problem). The technician can then open the
comprehensive template (which includes all possible sections) without worrying about losing
information already entered.
CC & History-
Hover over this area of the screen to display a snapshot of the patient’s chief complaint and
medical history (if they are a returning patient). This information can be quickly reviewed. Use
HPI facility to complete this information for a new patient.
Chief complaint & patient history
Quick Tip: Hovering the mouse over the “Chief Complaint” or “Patient History” boxes for a few
seconds in Work View will expand the box and allow user to see all the information within.
User Logged In-
At top, shows who is currently logged into the system.
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Admin User logged in
Neuro/Psych-
Select condition from drop down list to reflect patient’s current mental state. This is required for
a comprehensive examination.
Neuro/psych drop-down
AD (Advance Directive)-
Click on AD to display advance directive information. Use the drop- down list to specify the type.
Click on Scan to scan a new document into the system. AD-No signifies that Advance Directive
documents have not yet been uploaded.
Is there anything that could affect testing results?
Note whether the patient has a prosthesis, phthisis, or has poor view. Each of these will change
what is displayed on the system’s test screens and its selections for testing purposes.
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Select defect
Other Chart Note Fields:
Assessment and Plans
Assessment and Plans
To insert a preconfigured assessment, begin typing the first few letters. A drop-down list is
displayed where the assessment required can be selected. Free text can also be entered in
these fields. Red and other colored assessments are the doctor’s and should be selected by
preference. These have linked plans. Non-colored assessments in the list have no associated
plans.
Quick Tip: The physician’s assessments and plans. If an assessment is findings based the
assessment will be automatically copied to the assessment area based on entries made in other
parts of the chart. If not, it is easily entered.
Click on Orders/Order Sets to enter more detailed assessment and plan information based on
the set up in Admin’s Assessment and Plan policies, which are a part of the system’s smart
charting. Check the plans to be entered for the current assessment (which may not be all of
them).
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For a returning patient:
• NE Not Examined and therefore not charged for this time.
• RES Resolved, which will be charged for this time but not carried forward to a future
chart. A resolved assessment turns green.
If patient has a new medication, click Orders And Order Sets > Meds. A popup listing
medications is displayed. To select a medication, enter the first letter of the medication. The
highlight will jump to that medication in the list.
Goals & HC-
User can detail health goals and health concerns.
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Pt. Health-
User can add details about the patient’s health status (functional and cognitive).
Change the order of the assessments: To change the order of the listed assessments click on
the number of the first assessment whose position is to change and on the number of the
assessment where you would like to place the first assessment clicked. The positions of the two
assessments are changed. You might want to do this so that the order of the assessments
matches the automatically entered order of the diagnosis codes in the super bill. Click Done
after entering assessments and plans.
• Follow up (F/U): When the physician wants the patient to come in for a follow up
appointment. Below, user can also give transition of care information, reason for
referrals, and pt. discussion/comments. This box will expand as information is typed,
allowing user to write detailed comments. When the page is loaded, this box will expand
and display all content without user having to scroll.
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Signatures and details of caretakers (e.g. colors used to represent them). Green for a
technician, light blue for a physician.
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Super bill: The part of the template used for billing, and coding out the examination.
After clicking Super Bill, the system will determine the complexity of the examination—
straightforward, or of low, moderate or high complexity?
Next, it will evaluate the entire examination. The super bill utility will select diagnosis codes used
according to user’s chart entries. Pick the top four diagnosis code options. (The diagnosis codes
will be entered to the Dx Codes box at the top of the super bill area. These depend on entries in
the Assessment and Plan area.
A second popup will ask the user whether the patient is new to this practice. The super bill
routine will then display the levels for Eye Code and E/M Code purposes that are met, that are
qualified for, and what needs to be done to reach the next level.
19
The appropriate CPT code for the visit is then inserted to the CPT fields (seen above) and is
linked to the entered diagnosis codes. Other CPT codes are entered by the user by typing in the
code (if known) or, if not, by entering the description of the procedure.
Dx Assist- If user manually adds a CPT code, clicking Dx Assist will push this information
forward automatically.
VIP- Indicates this is a VIP patient, who may be entitled to discounts/benefits, etc.
Print Meds- Prints a list of patient medications.
Follow up
● Transition of Care--Enter the name of the doctor to whom the user is transitioning the
patient.
● Consult--Create a consult letter.
● Pt. Instructions—Links to Patient Instruction Documents
● ePost It—An electronic post it. Notes can be written here; this will disappear once the
chart has been closed.
● Pr. Note—Progress notes on the patient. This allows has the option to Print, or use
Voice2Text. User can select previous or current notes.
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● To Do—Allows user to add comments/reminders for specific patients.
● Scribed by--If scribed, the name of the scribe can be entered.
● Comments Requested by Patient--Comments requested personally by the patient can be
entered to this area.
● Recalls and Future Appointments (Internal and External) -- For your information the
details of recalls entered to the system and of future appointments are displayed in this
area of the chart. There is also a purple link to the ASC-Surgical Ocular History.
● Signature-- The physician’s signature is automatically entered when the chart is
finalized. Note that currently the user is only finalizing the medical portion of the chart.
The billing information can subsequently be amended by billing staff. The financials are
not fixed at this point.
● Signer Name-- This is also automatically entered when the chart is finalized.
● Care Giver Colors Key-- The background color of the fields for various care givers.
Generally, the physician’s entries have a blue background, those of the technician green.
● Making Changes to The Chart After Finalization-- The physician who finalized the chart
can make changes to the chart for up to 3 days (or the time specified by the Chart
Review timer in Admin). The physician is warned that the Chart Note has been finalized
but can still make the change. Click Save to save the changes made.
● EDIT-- After the three days that the physician must make changes an [EDIT] button is
displayed. The physician can click this to create a formal and dated amendment to the
finalized chart note. The fact that the chart has been amended is recorded by the
system.
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Toolbar Icons
Test Manager
Located on the main chart, at top, the test manager icon allows the user to manager test images
and interpretations.
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eRx
These icons bring you to the ePrescribing system. Please see the eRx Guide for more
information.
General Health
This green icon will display a general overview of a patient’s medical history, including allergies,
surgeries, medications, etc.
23
Smart Charting
24
Smart Charting allows users to quickly assess different portions of the patient chart. User can
note symptoms, severity, and add assessments and plans here as well.
Pt. Communication
Allows user to leave a verbal message for a patient.
25
Pt. Instruction Documents
Like the button in the Follow Up portion of Work View, this icon at top links to Patient Instruction
Documents.
Allergies-
Click this icon at the top of the screen to display a popup that shows the patient’s current
allergies (entered via Medical History). A green icon indicates there are no allergy problems.
Allergies icon
Surgeries
Lists ocular surgeries, including site, date, attending physician, and comments.
26
Flow Sheets
Glaucoma Flow Sheet
A specialized flow sheet for Glaucoma patients. Diagnoses, Medications, Surgeries, etc. can all
be taken here. At bottom, user can log IOPs, assessments and plans.
Patient Refractive Sheet
27
This green icon opens the patient refractive sheet. This displays patient prescriptions for glasses
and contact lenses (soft and gas permeable). CL Order Hx button, at top right, displays the
contact lense order history.
Print Patient Summary
Allows user to print a comprehensive patient record. User can choose to add or exclude
information as they see fit.
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MUR Checklist
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A checklist for Meaningful Use Requirements.
Chart Note Sidebar Clicking the three vertical dots at the right of the chart opens the sidebar. Note that these
functions can be pinned and changed as user desires.
30
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1. Toric Calculator
Links to toric calculator images. You have options to assign to current patient, or delete as
necessary. In the upper-right corner, you have an option to launch the actual Toric Calculator
from this screen.
2. History of CPT Services
A history of CPT Services and their charges.
3. Patient Chart Search
Allows user to search for a specific patient’s chart via text.
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4. Patient Providers
List of patient providers. There is an option to Print in the top right corner.
5. Confidential Text
Allows user to add confidential patient information, and authorize providers and groups to
access it. Also displays a list of access history (who accessed this information and when).
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6. Primary Referrals
List of primary, secondary, and tertiary referrals.
7. In Patient Data
Allows user to enter Inpatient Data, including Discharge Disposition Code and Principal
Diagnosis Code.
8. Patient Payer
Displays Patient Payer insurance information.
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Patient Instruction
Here, user can find forms to give to patients for various disorders and procedures
Patient Forms
Patient insurance and case type are displayed under this icon. User can also click for more
information to search exam and test diagnoses.
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Closing a patient’s chart
To close a patient’s chart, click the red X at the right-hand side of the screen, seen below.
Chief Complaint
After taking the Medical History, technicians will often enter the patient’s chief complaint (the
reason the patient is presenting). Although information can be free-typed, iMedicWare suggests
the use of the HPI (History of Present Illness) function, so the requirements of a comprehensive
examination are included.
As mentioned, a Chief Complaint requires at least four modifying factors (Location, Severity,
Duration, Onset, etc.). Using the HPI prompts the user for these factors. The age and sex of the
patient is already entered.
There are two types of entries:
36
1. Enter minor complaints by clicking a check box in the HPI to indicate the condition is
present. As many as required can be entered. Minor complaints are listed after the Chief
Complaint.
2. Click the text label (description of the condition) to enter a chief complaint along with its
modifying factors. A maximum of three detailed chief complaints are allowed per visit.
Quick Tip: Each chief complaint entered is numbered by the system, but if the user free types in
the area (this is permissible), the system cannot tell whether the four modifying factors condition
has been met. A chief complaint that meets the modifying factors criteria will turn purple.
Click on HPI to begin. The following screen is displayed:
HPI pop-up
The sub-tabs displayed reflect different reasons for the patient’s visit. These include:
● General vision problems
● Specific types of irritation
● Post segment disorders
● Neuro disorders
● Follow ups
37
Remember that a minor complaint is entered by clicking an item check box on this screen and
clicking Done without specifying any factors required to create a chief complaint.
Entering a chief complaint
Specifying the modifying factors for the complaint “driving at night”
Click the description of a problem on any of the HPI screens, e.g. Driving at night. An input
screen will allow you to specify four (or more) modifying factors for the chief complaint. The
technician can select a value from any of the following modifying factors:
● Location
● Quality
● Severity
● Onset
● Duration (of episodes)
● Context
● What makes it worse or better?
Click [Done] to create the chief complaint, which will appear numbered and in sentence-style in
the Chief Complaint field. It will look something like this:
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A 58 Yr. old male patient
1. Complains of Difficulty in Driving at night in both eyes. Which began less than
1 months ago. The episode is constant. It is described as aching, burning and
glare. The complaint severity is increased. It is worse: night . The complaint
occurs when outside. It is Associated with blurry vision and dizziness or light-
headedness.
The above factors included in this numbered chief complaint are:
● Location (both eyes)
● Quality (aching, burning, glare)
● Onset (less than 1 month ago)
● Context (when it happens)
● What makes it worse (night)
● What it is associated with (blurry vision, dizziness)
After entering a chief complaint, the user can go back and edit any of the automatically entered
information or type in additional details.
Upon completion, a valid chief complaint is automatically numbered by the system. A maximum
of three chief complaints can be entered per visit. There is no limit on the number of minor
complaints that can be entered.
Vision Exam
Vision chart
You may also clear all Vision Exam Data by clicking the Reset icon.
39
Reset icon
If you are creating a new chart for an existing patient, all the information from the patient’s
previous chart is automatically filled in and the fields are colored gray. Clicking inside a field
changes its color, verifying information is up-to-date.
Each section of the vision exam has a comments section for free-format comments. You may
also reveal and hide chart sections by clicking the carrots. For example, if you wish to hide or
display BAT/PAM settings, click the “Vis. Acuities” carrot. Physicians/Scribes should become
familiar with these settings so that they only display their preferred vision exams on the chart.
Distance and Near Vision (AR and K)
There are three ways to enter information into the chart.
● Clicking into a field and typing
● Using the drop-down arrow to the right of a field
● Clicking the checkmark to indicate no change
40
Present Correction
Again, you may click the i to fill in fields.
2. Copy: Allows you to copy data from other PC or MR fields.
3. Green plus sign: Click to add additional information.
4. Click to print.
Manifest Refractions (plus GL and PH)
Manifest Refractions screen
In the MR (manifest refraction) section of the vision exam, user can switch between plus/minus Cyl, and add as many manifests current to the prescription by clicking given-- which sets the marked date to the current Rx
1. Over Refraction / Prism : Clicking this opens additional fields to record this information.
41
Cycloplegic
Cycloplegic drop down menu
Contact Lenses
Contact lenses chart
1. CL Worksheet: Click to open the worksheet in a separate window, which allows you to enter
large amounts of information easily. User must check the CL-REQ box at top to make current
that Rx.
2. Copy from: Allows you to copy contact lens data.
3. Save: Remember to save any changes you make in this section.
4. Click the eye icon to make a simple contact lens drawing.
42
Contact Lens drawing
Contact Lens Worksheet
Open the contact lens worksheet from the Workview Dropdown at the top of the screen, or from
the contact lens portion of the chart.
43
Contact Lens Worksheet
The worksheet allows you to quickly enter information by typing in each field, or by using the
drop-downs that appear when clicking in each field.
Contact lens worksheet cont’d
44
Add more columns
Clicking the green plus sign will allow you to add additional columns. You may add multiple
contact lens trials in one worksheet.
● The green pencil icon allows you to enter contact lens fitting details in one window.
Information is automatically entered in the corresponding fields in the worksheet.
● The pink printer icon allows you to print a contact lens prescription.
45
Order buttons
You may also place an order for contact lenses using the [Order] button. The order will be
automatically sent to the Front Desk when completed. [Order Rx] in the upper-right allows you
to view order history.
Remember to click [Save] before closing the window.
Confrontational Vision Fields, Amsler Grid, and others
Clicking CVF, Ams Gd., or the corresponding squares will display the associated fields.
Click WNL if results are Within Normal Limits. If results are unchanged
from the patient’s previous chart, click NC.
46
Confrontational Field
Amsler Grid
In this section, you may also record ICP Color plate, Stereopsis, Retinoscopy, and
Exophthalmometer results.
ICP Color Plate and Stereopsis
If the user is examining a new patient, ICP color plate testing is likely to be included, along with
a stereopsis evaluation. Both examinations are also available via the EOM screen, and both
areas are linked and keep each other updated.
The ICP Color Plate indicates whether the patient can determine the control plate (with + or -)
and then, for each eye, how many plates out of the total the patient is able to distinguish (e.g.
8/10). Additional notes can also be entered.
Stereopsis: Enter the seconds of arc.
Summary Examination Chart
47
These sections allow you to record information about anatomical findings:
Summary examination chart
• Clicking the name of each section (Pupil, EOM, External, etc.) will open a window where
you can record your findings. In these windows, you can also record an audio or video
file to attach to that section.
• Clicking the WNL or NC buttons in a section will affect only that section.
• Clicking WNL or NC on the purple bar will mark all sections as such.
48
NOTE: Clicking WNL will not overwrite any information you have already recorded, so it does
not matter which you click first.
• Resets all sections.
49
• Record a new audio or video file or play a saved one.
• Open the drawing tool
50
Drawing Tool
Drawing Tool
The left side contains tools such as pencil, text, shapes, and colors. The right has premade
drawings of anatomical conditions. After inserting a premade drawing, you may resize and/or
rotate it.
Other functions include:
1. Change the drawing template
2. Select an image from this patient’s tests to open in the drawing tool
3. These four buttons allow you to enter new images into the drawing pane:
a. Scan an image
b. Upload an image file
c. Take a picture with your computer/mobile device’s camera
d. Open a new drawing pane
The drawing tool connects with the patient chart; entering information (such as a retinal tear) in
the chart automatically generates the corresponding drawing in the drawing pane. You may then
make modifications in the drawing to match the patient’s condition.
Making a drawing will also generate the corresponding information in the patient’s chart.
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Gray and White Field Backgrounds
Distance & near charts
1. In a new chart the background of the chart fields will be white, but for a returning patient,
grayed out areas in the chart are areas that have not changed since a previous visit.
2. Fields will only change color when information is changed during the current visit. When
the user clicks into a gray field, its background color changes to show the content has been
updated.
The only information not automatically carried to the next chart for a returning patient is:
● Chief Complaint
● Pressures
● Physician’s Plans
The Examinations
Click on the name of the examination to enter your findings. If the results are normal, user can
click WNL (within normal limits).
When completing Bilateral (or BL), it copies findings from the Right Eye to the Left Eye, so the
user does not have to repeat them. Use the Bilateral command at the top of the screen to copy
all entries at once, or choose the individual line BL to copy one item at a time. This utility only
works in the direction OD > OS.
52
Bilateral option
More/Usually Advanced Options: Sometimes a screen has more options than can be
comfortably displayed on the screen. To access these additional options, click on the word
“ADVANCE” or any downward arrows that appear to the right of certain fields. In some
instances, there will be an advance bar which when clicked displays further options.
Quick Tip: Normal comments will only be inserted in blank areas. If the test already has items
commented, these will not be overtyped with any normal indications after clicking WNL.
Main Sections of the Summary Examination Chart
● Pupil
● EOM (Extra Ocular Movements)
● External
● L&A (Lids & Adnexa)
● IOP (Intra Ocular Pressure)/Gonioscopy
● SLE (Slit Lamp Examination)
● Fundus (including retinal exam)
To open a subtab for each summary examination item, double click on the color examination bar
and a pop-up window will appear.
53
Pupil
Pupil Medx chart
If everything is normal, click WNL, otherwise enter specific findings and comments. Click on a
finding to select it and highlight it in red. Save changes by clicking [Done]. The shape of the
pupil is defined in this part of the system.
• Note the size of the pupil--click on the first field of the exam area
• Scotopic is the pupil size under low light condition.
• Photopic is the pupil size with light.
• Dilated refers to the dilated size of the pupil.
• RL is the eye ball movement
• RA is the pupil reaction time with light.
• APD is the Afferent Pupillary Defect
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EOM (Extra ocular movements) & Other examinations
Extra ocular movements
The technician indicates whether this is Within Normal Limits (WNL) by clicking on the WNL
button. Alternatively, they can signify there has been no change. Where the problem is not
within normal limits, the technician can investigate further and mark items off. This area includes
another version of the Randot Stereo Test and the ICP Color Plate. Both areas (Main Chart
Note and EOM examination) continually update themselves.
External
External exam
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The Technician indicates whether there is external damage to the eye area. This is for problems
that can be visually observed, like a black eye. Again, the technician will indicate whether this is
within normal limits (WNL) or if there has been no change. Where the problem is not within
normal limits, the technician can investigate further.
Lids & Adnexa
Lids and Adnexa chart
This is concerned with the eyelids and adnexa and includes lid positions, the lachrymal system,
and lesions. It is associated with a drawing tool (See below).
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Lids and adnexa drawing tool
1. Select a template by clicking one of the choices at the top of the screen.
2. Change the template to meet requirements by using the supplied tool bars.
Main Points:
● Commonly used drawing tools are displayed top left
● A shapes toolbar is available for use in the top right corner of the screen
● A common shapes and lines toolbar with specific types (each linked to a tool tip for
assistance) is available in the bottom right corner of the screen
● A list of fill colors is available at bottom left
● A list of conditions is shown on the right. Hover over for a description. After entering,
right click to enter a description and display further options related to the condition.
These can be charted while using the drawing tool without having to select these
options from the Examination Chart.
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IOP/Gonio
IOP
Gonioscopy
This screen is used to enter pressures and details of administered eye drops (for both dilation
and anesthetic purposes). To enter more than one of each, click the green plus sign. To note
the IOP time, click on IOP/Gonio. Click on a medication or a combination of medications to start
the dilation timer. If the patient is squeezing, or if the test is unreliable or was unable to be
performed, check the appropriate box. The time of dilation is automatically tracked for iMonitor
purposes and the user’s information.
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The user can also record indications such as the unwillingness of the patient to be dilated or
inability to dilate. If the user clicks on Patient Allergic or Patient Refuses to Dilate, further
comment fields are displayed so an explanation can be entered.
Anesthetic and Dilation Drops--Note the types of anesthetic and dilation drops used, and add
an IOP that notes the time it was entered. Mark which eye was dilated. Indicate warnings given
to the patient (e.g. you will have blurry vision, advised not to drive, etc.). For a minor, indicate
that permission for dilation was given by a guardian/parent.
Pressures
● Ta Slit lamp tonometry (e.g. Goldman Applanation, other applanation)
● Tp Pen tonometry or pneumotonometry (puff)
● Tx Any other method
● Tt Tactile assessment (of a child for example).
If required, historical pachy readings can be entered at the top of the screen. Do not enter any
readings taken today.
Physician Notes
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Opens a window for the physician to take notes on Diagnosis, Ocular Sx, Consult, and Med Dx.
Patient Information
To access the main Patient Information Screen the Front Desk operator clicks the patient
information drop down seen here:
Patient info drop-down
Patient Information Screen
Here the user can carry out many patient-focused tasks, including:
• Changing the status of a patient
• Display demographic history changes
• Update patient’s physician details
• Change a patient’s language, ethnicity, race, occupation
• Set up Advance Directive details
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• Set up patient access to patient portal
• Release medical information to relatives
• Set up Responsible Party/guarantor details
This part of the system securely holds all patient demographic information.
Edit Patient Information
Click on the Patient Info tab at the top of the screen. The user can correct any demographic
information necessary and click Save Patient.
Display Patient’s Demographic History
Demographics Hx
Demographics Hx
Click to display changes in the patient’s demographics, including name, marital status,
gender, social security and date of birth details.
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Change Language, Ethnicity, Race and Occupation
This information is required by CMS Meaningful Use rules. Select all values from the supplied
dropdown lists. Enter manually the employer address, zip code and city. If the details are not
currently on display, click to open them.
Consent Forms
All necessary forms can be found in the folders on the left side of the screen. User must have
the patient read through the forms and then sign them using the electronic pad; click on the PEN
icon adjacent to the signature area and the electronic signature pad will be activated. Clicking
on the red eraser will erase the signature. Clicking on [Save And Print] causes the system to
generate a .pdf file. The form is automatically filed in the Signed Forms folder, which you will
find at the top of the folder list. The practice will now have a copy of the document on file with
the patient’s signature for the specific DOS.
Taking the Patient’s Medical History
Medical Hx-Ocular
Using this set of related screens, the Technician notes why the patient is in the practice today
and asks the patient questions such as the date of the last eye exam. This is one of the first
things the technician will do. After clicking the tab, the first of 13 Medical History screens (not all
are required) is automatically displayed.
The Medical History module provides fields to capture a wide range of information--sometimes
much more than required by your office. The user should only complete those fields that are a
part of the office’s customary workflow.
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Quick Tip: The user will not have to enter the full medical history information each time that the
patient comes into the office. It is carried forward from earlier visits to the patient’s subsequent
charts.
Procedures
Allows user to take notes for certain procedures. This includes info such as CPT codes, start
and end time, medications, etc. There Is a checkmark if the patient is at risk for heart attack or
stroke. This page also links to consent forms and Op reports.
At bottom, User can select a physician to hold for, and print. There is also a superbill section at
the bottom of the procedures page, for easy billing.
Add New Procedure
1. Click New Procedure.
2. Name the procedure.
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3. Specify whether the procedure updates the Retinal or Glaucoma flowsheets. If neither,
choose Other.
4. Enter the procedure’s diagnosis code.
5. Optionally, select a Consent Form and an Op Note to be associated with the procedure from
the appropriate drop downs. The form will appear in the lower half of the screen so that it can
be signed by the patient.
6. Enter any pre-Op medications associated with the procedure. Type ahead is available.
7. Enter any intravitreal medications associated with the procedure. Type ahead is available.
8. Enter any Post-Op medications associated with the procedure. Type ahead is available.
9. In the 3-column table in the lower half of the screen enter associated CPT codes and any
modifiers. 10. Click Done.
Tests
Tests
To perform a test, the user chooses the required test from those listed. The interpretation sheet
for the test is displayed. To upload a test, click the upload icon shown below and add your files.
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To view tests on the chart, user can go to the tests history section and click date of service. The
test will then appear.
Quick Tip: The user will need to select the correct physician at the top of the form, or the details
will be sent to all physicians, which could create confusion.
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ICG Test example
Then, enter any comments about the test.
Finally, the user will use Upload to upload to the chart any images taken or Import to import
images into the chart from connected ophthalmic machinery. Hit Done to send a notice to the
physician that there is a test to be interpreted. The date of the test (that also functions as a
direct link to the test results) will also be inserted into the yellow bar above the assessments and
plans area of the patient’s chart (see below).
IMedicMonitor
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iMonitor is a module that connects with iDoc and provides a visual chart of all checked-in
patients in your practice. This module allows techs and physicians to track patients’ progress,
ensuring no patients are left waiting for long. You will need to enter your practice’s iMonitor URL
and log in to access the system.
There are two views: Standard View and Room View. You can switch between them using the
button in the upper-left.
Normal View
The areas of the screen are:
1. Physician Active List: Patients the physician is currently seeing.
2. Tech/Active List: Patients that the techs are currently seeing.
3. Waiting Patients/Test Active List: Patients getting a test or dilating. A 20-minute countdown
timer appears for dilating patients.
4. Waiting Room: Patients that have been checked in.
5. Scheduled Patients: Patients that are scheduled for today, but have not been checked in.
Room View
To use the Room View functionality, each Physician will need to set up their own Room View
Profile(s) based on the lanes that they utilize on a given day. The Physician can create multiple
profiles if their lanes change depending on the day of the week, time of day, etc. Each Physician
will give each profile a unique name to identify which profile they will need and when.
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To create a profile, go to settings by clicking the button in the top right corner. This
opens the Settings Window. From the Settings Window, select from the Room Profiles
dropdown, and select Add New Profile.
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Once the Physician has given their new profile an appropriate name, click Save.
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Once saved, the screen will change to a profile definition screen where the Physician will
indicate which rooms to include as component of the profile’s lane. To select the rooms, check
the box underneath each of the rooms. Once all desired boxes are checked, click Save.
Once saved, the profile will be selectable as a Room Profile.
Now, when entering iMonitor and selecting Room View, the office can select a Room Profile to
view the status of each patient within that lane’s pipeline. This will display patients that are:
• On the schedule but have not yet checked in
• Have checked in and are in the waiting room
• Currently with a Technician, and which room they are in
• Currently with a Physician, and which room they are in, and their priority status
