Documenting With a Smarter Ophthalmology EHR

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Here is a full transcription of the video:

This is a view of our chart. Our histories are on the left, and on the right hand side are the visits in chronological order. I’m going to go right into my intake history. I’m going to add a chief complaint and I’m going to add blurred vision. I’m going to say they’re blurry in both the right and the left eye. And I’m going to answer questions about their blurred vision. They’re blurry at all distances, it’s a relieved by closing an eye, it’s moderate in complexity, it’s been going on for six months, and when I saved my complaint, I have a grammatically correct paragraph stating why my patient is here.

I can always override and edit or dictate anything. And if you notice, HPI components down below are all filled in. The patient states they have a history of blepharitis though they are not complaining of itching today, and voila. In the exam, I can pinch and zoom on any diagram or setup for ICD-10 specificity.

You can do freehand drawing. I’ll show you we can just touch draw, and then mark in numbers for gonioscopy. We can also use glyph tools which are pre-drawn pieces of artwork that I can document on any portion of the eye which will put those findings in my exam. You can pull forward exams, findings, impressions, plans and drawings, but this is what your exam will look like. You can document your findings in the areas down below. I’m going to put my findings here for the lens. I’m going to put my findings for the left eye as pseudophakic, we’ll go to the discs, will put in a 55 and copy it to the other eye with one touch.

The next thing that I’m going to do is show you our Protocols, which are preemptively built in diagnoses and every plan of action you could possibly think of to match. Another way to document is by using a diagnosis-driven approach. I can pick a diagnosis on the left hand side. I can pick findings from the findings box, select what I want, and route them to the appropriate eye or eyes by touch. There’s my gonio. I’ll write a prescription. I’ll pick what I’ve used most frequently.

We’re the only system that gives you formulary Rx plans. They will show for you on the right and I can send this prescription by ePrescribe. Fill in only the quality measure that matters. All of my charges are there. I got the proper coding. These are the things that I qualified for. I’ve got my entire visit note. This is everything that we documented today. I haven’t typed in a thing. 

 

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