Opening Screen for your Drs.

Preliminary Notes (This will be the first screen you will see after signing into the iPad).

Once you click onto a patients name it will open up the screen for their chart

The call button, tasks button and alert buttons will be explained when we start implementing them in our practice
 Clicking on the Pt’s Name in the top left hand corner will bring up the patients demographic information

Clicking on the more button will open up various options you can use to view various parts of the patients chart
 Inside the more tab you can view the clipboard/ see attachments under photos and view the patients eye log

Clicking on notes will allow you to change/edit the yellow sticky note seen at the top of the screen on the desk top
Once you click on a patients name their individual chart will open and you can see the CC/ROS/Pretesting/Exam
notes/ Impressions and PSFH of the patient
Clicking on the two small double arrows at the bottom right hand corner of the boxes (indicated above by the yellow
arrow) will expand and open that portion of the documentation so you can fully review this area

Clicking on the manage button will open and give you the option to edit the visit settings for that visit
This is where you can edit your provider, change new or existing patient statuses and where you put your name in as
the scribe

Entering into the exam for the day of the visit. Once you click on Exam at the top in the purple bar it will take you to
this screen
If your Dr. starts by looking at the OCT a trick to remember the findings if you don’t have a diagnosis would be to put
the OCT in under Retina Tests then replace the title (diagnosis) when you know what it should be
Make sure you fill out your Details, Findings, Diagnosis, Assessment and Plan and confirm that the billing is correct
Make sure that you are changing your machine to match which model you have in your office

Once you Input the OCT and you figure out what Diagnosis you need to associate it with you can replace the Dx to
whatever it needs to be (In this case Wet ARMD)
 Entering in the Lens and Discs/ creating the fundus portion of your eye exam

This window will appear and the ONLY eye exam that we should be using is the Eye Exam (DO NOT use postop eye
exam even for postop patients)
 From here you can fill out any of the AC/External findings, the Lenses and the Discs

This is where you also go to filter whether you are looking into both eyes or just one eye. If the patient declines
dilation this is where you also indicate this. Advanced mode will take away the preset options and allow you to type
in your findings within the fundus tab.
(Inputting an Impression for the first time) On the left hand side of the screen you will see a Diagnosis tab click on that
and the most used diagnosis will populate in this list. If you do not see your diagnosis you can click on the magnifying
glass in the top right corner and search for your diagnosis.

Once you choose a diagnosis (in this case Wet ARMD) the plans tab on the left hand side of the screen will populate
all the testing and diagnostic tools that can be used under the diagnosis Wet ARMD. On the Right hand side of the
screen the grading and severity will pop out for Wet ARMD. (Anything that Highlights blue on the right hand side of
the screen MUST be filled out to meet ICD 10 guidelines.
 In the ICD 10 Expert for Exudative ARMD (Wet) will give you the options of Active Choroidal Neovascularization,
Inactive Choroidal Neovascularization or Inactive Scar. You must choose one it should never be unspecified you do not
have to stage both eyes if the diagnosis is just for one eye you can leave it blank like the example below.

You MUST fill out the findings every time as well! The Severity Scale should match your ICD 10 Exp. If you have
NonExudative ARMD (Dry) and there is GA IT IS ADVANCED!
To Input findings (Morphologies) into the fundus part of the exam scroll down under your severity findings and you
will see morphologies that have already been created or you can create new custom morphologies if needed. Once
you select the morphologies that are relevant for the diagnosis you are in you must click which eye you want the
morphologies to go under or it will place them in both eyes.