Exam Tab

The Exam tab allows the data abstractor or quality reviewer to add, edit, or delete medical events and procedures associated with the patient visit.

Exam Tab Screenshot

Adding, Editing and Deleting Events

To add a new event

1.      Select the event from the Event Type list.

Event Type Drop Down

2.      Enter the corresponding information for the event. The available fields differ depending on the event, as shown in the table below.

3.      Click Save to save the event details.

To edit an event

1.      Click the corresponding Edit link.

2.      Make the necessary revisions by selecting from the drop-down fields. The available fields differ depending on the event, as shown in Table 3.

3.      Click Update to apply the edits, or Cancel to exit without saving.

To delete an event

      Click the corresponding Delete link, and then click Yes to confirm.

 

Table 3: Exam Tab Events and Fields

Table 3: Exam Tab Events and Fields

 Event

Fields

Angle Recession

Anterior Chamber

Brow

Confrontation Visual Fields

Conjunctiva

Cornea

Depth Perception

Functional Testing Field

Globe

Intraocular Pressure

Iris

Kinetic Visual Fields

Lens

Lids

Motility Extraocular Muscles

Optic Disc

Orbit

Pupil

Relative Afferent Pupil Defect

Retina

Scelera

Static Threshold Perimetry

Visual Acuity

Vitreous

Laterality: Select the affected eye, i.e., left, right, both, or not specified.

      Laterality Drop Down

 

Was the Test Performed? Select Yes, No, or Not Documented.

     Test Performed Drop Down

 

Selecting “Yes” will display the Test Result and Visit Data fields:

 

Test Result: Select the result, i.e., Normal or Abnormal.

Test Result Drop Down

 

Visit Data: Select the corresponding test data from the drop-down list and click Add.

Anteriror Chamber Visit Data

 

Comments: Type additional clinical comments in the free text field.

 

Some events provide additional data fields, as outlined further in this table.

Angle Recession

Visit Data (visible when the “Was the Test Performed?” field is set to Yes)

 

Select the event detail from the drop-down list.

    Angle Recession Visit Data Drop Down

 

Clock Hours: Select the number of clock hours (1 – 12) of angle recession from the two drop-down lists.

 

   Angle Recession Clock Hours

Color Vision

What Test was Performed / Additional Details: Select the corresponding test and type any additional details in the free text field.

 

Number Correct / Total Number: Type the corresponding numbers in the text fields.

 

    Color Vision Screenshot

 

Depth Perception

Depth Perception (visible when the “Was the Test Performed?” field is set to Yes)

 

Randot Fly / Verboeff Stereopter: Type information related to the corresponding test types in the free text fields.

 

Angle of Stereopsis: Select the test results, in seconds of arc, from the corresponding drop-down lists.

 

Depth Perception Screenshot

Functional Testing Field

Functional Testing Field (visible when the “Was the Test Performed?” field is set to Yes)

 

Enter the Functional Testing field results in the indicated formats.

 

Functional Testing Field Screenshot

Imaging Ancillary Testing

Imaging Ancillary Testing

 

Imaging Methodology: Select the imaging methodology from the drop down list.

 

Test Date: Enter the test date in M/D/YYYY format. The date can be spelled out, but it will revert to numerical format.

 

-Or-

Use the Date Calendar Button selector to select the test date.

 

Test Result: Type the information about the test result in the free text field.

 

Imaging Methodology Drop Down

 

Click the Add link to add the record to the image testing list.

Intraocular Pressure

Intraocular Pressure (visible when the “Was the Test Performed?” field is set to Yes)

 

Type the corresponding information into the free text fields, i.e., Method, Comments, Number (0-99).

 

 

 

Type the time into the text field (standard time will be converted to military), or use the clock Time Buttonto select the time.

 

Intraocular Pressure Screenshot

 

Kinetic Visual Fields

Kinetic Visual Fields

 

Methodology: Select the field kinetic testing methodology from the drop down list.

 

Result: Type the information about the test result in the free text field.

Kinetic Visual Fields Screenshot

 

Click the Add link to add the record to the test method list.

Motility Extraocular Muscles

Motility Extraocular Detail (visible when the “Was the Test Performed?” field is set to Yes)

 

Select the corresponding eye movement details from the drop-down lists. If “Abnormal” is selected for Saccades, this enables a free text area for additional comments.

 

To add additional records, select the corresponding condition from the Motility and Cranial Nerve lists and click Add to add the record to the list.

Motility Screenshot

 

Prosthetic Devices Ordered

Prosthetic Devices Ordered

 

Laterality: Select the affected eye from the drop-down list.

 

Laterality Drop Down

 

Options: Select the type of prosthesis from the drop-down list and click Add to add it to the list of devices.

Prosthetic Devices Ordered Options Drop Down

 

Implant Types: Select the implant type from the drop-down list and click Add to add it to the list of implants.

 

Prosthetic Devices Ordered Implant Types Drop Down

 

Pupil

Pupil (visible when the “Was the Test Performed?” field is set to Yes)

 

Size: Type the pupil size (1-10) in the text field.

 

Alterations in Shape: Type additional information into this free text field.

 

PERRL or PERRLA / Reactive: Select the corresponding assessment and reactive setting.

 

Adie’s / Argyll-Robertson: Click Yes or No for the presence of Adie’s syndrome or Argyll-Robertson pupil.

 

Pupil Screenshot

Relative Afferent Pupil Defect

(Visible when the “Was the Test Performed?” field is set to Yes)

 

Relative Afferent Pupil Defect: Select Yes or No for the presence of the condition.

 

ADP: Select the ADP status, i.e., Negative or Positive.

 

Relative Afferent Pupil Defect Screenshot

 

Static Threshold Perimetry

Static Theshold Perimetry (visible when the “Was the Test Performed?” field is set to Yes)

 

 

Reference Scale: Select the reference scale from the list.

     Static Threshold Perimetry Reference Scale

 

Deviation / Fixation Losses: Type the mean and pattern standard deviations, as well as the fixation losses in the indicated format.

Static Threshold Perimetry Screenshot

Symptoms

Visit Data: Select the symptom data and click Add to add it to the list.

 

Symptoms Screenshot

Visual Acuity

Visual Acuity (visible when the “Was the Test Performed?” field is set to Yes)

 

Scale: Select the standard of measurement from the drop-down list.

 

Visual Acuity Scale

Enter the corresponding information for the selected scale. The exact selections differ depending on which scale is chosen, but all scales show areas for Scale, Refraction and Qualifiers. The example below shows selections for the Jaeger scale.

 

 Visual Acuity Screenshot

 

Visual Functioning Questionnaire

Questionnaire / Score: Select the visual functioning questionnaire and enter the corresponding score.

 

Visual Functioning Questionnaire Screenshot

Review Comments

Review comments can be added to the Chief Complaint tab by the quality reviewer. The data abstractor can then view the comments and address them.

If a field is enabled for review comments, three comment buttons will be visible over that field.

Reviewer Comment Closed Screenshot

      To expand the comment if it is not visible, click the Expand Reviewer Comment - Expand Buttonbutton.

      To close the comment, click the Close Reviewer Comment - Close Button button.

      To save the comment, click the Save Reviewer Comment - Save Button button.

NOTE: Any changes made to the Review Comments area will not be saved unless the Save Reviewer Comment - Save Button button is clicked. That is, clicking the Save button on the Encounter Actions menu will not save these changes.

To update the record after review comments have been received (Data Abstractor role)

1.      Make the necessary revisions to the Chief Complaint tab based on the corresponding review comment.

2.      Once the comment has been addressed, click (select) the Resolved check box and click the Save Reviewer Comment - Save Button button to save the changes.

3.      When all comments have been addressed and the encounter is ready to be re-submitted, click the Send for Review link on the Encounter Actions menu.

4.      The quality reviewer will review the encounter, locating each comment and marking off the Approved check box for each revision that is approved.


 

To add review comments (Quality Reviewer role)

1.      Go to the area where the comment will be added and click the Expand Reviewer Comment - Expand Buttonbutton to open the review comments box.

Reviewer Comment - Expanded

2.      Type the comment in the free text field and click the Save Reviewer Comment - Save Button button. (The comment will not be saved unless this button is clicked.)

3.      When all comments have been added, click the Return to Abstractor link in the Encounter Actions menu to return the record for further processing. This will remove the encounter from the Reviewer Tasks grid until the data abstractor re-submits the record for review.

To approve changes after the data abstractor has made revision (Quality Reviewer role)

1.      Go to the field where the comment was added and resolved.

2.      If the review comment was addressed satisfactorily, click the Approved check box to select it, and then click the Save Reviewer Comment - Save Button button. (The setting will not be saved unless this button is clicked.)

Reviewer Comment - Expanded with Resolved and Approved Checkboxes

 

3.      Repeat this procedure for all resolved comments.

After all comments have been approved, the Review Comments grid in the General Tab will show the Is Approved check boxes as selected.

Updated Reviewer Comment List

 

Encounter Actions Menu

The Encounter Actions menu allows the data abstractor to save the record, send it for review, or cancel out of the current revisions.

Encounter Actions For Data Abstractors

Quality reviewers can use the Encounter Actions menu to save the record, return the record to the data abstractor after adding comments, send the completed, approved record to DVEIVR, or cancel out of the current operation.

Encounter Actions For Reviewer