To add a new event
1. Select the event from the Event Type list.
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
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. Was the Test Performed? Select Yes, No, or Not Documented. Selecting “Yes” will display the Test Result and Visit Data fields: Test Result: Select the result, i.e., Normal or Abnormal. Visit Data: Select the corresponding test data from the drop-down list and click Add. 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. Clock Hours: Select the number of clock hours (1 – 12) of angle recession from the two drop-down lists. |
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. |
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. |
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. |
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 Test Result: Type the information about the test result in the free text field. 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 |
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. 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. |
Prosthetic Devices Ordered |
Prosthetic Devices Ordered Laterality: Select the affected eye from the drop-down list. Options: Select the type of prosthesis from the drop-down list and click Add to add it to the list of devices. Implant Types: Select the implant type from the drop-down list and click Add to add it to the list of implants. |
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. |
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. |
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. Deviation / Fixation Losses: Type the mean and pattern standard deviations, as well as the fixation losses in the indicated format. |
Symptoms |
Visit Data: Select the symptom data and click Add to add it to the list. |
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. 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 Functioning Questionnaire |
Questionnaire / Score: Select the visual functioning questionnaire and enter the corresponding score. |
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.
•
To expand the comment if it is not visible,
click the Expand button.
•
To close the comment, click the Close button.
•
To save the comment, click the Save button.
NOTE: Any changes made to the Review Comments area will
not be saved unless the Save 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 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 button
to open the review comments box.
2.
Type the comment in the free text field and click the
Save 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 button. (The setting will not be saved unless
this button is clicked.)
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.
The Encounter Actions menu allows the data abstractor to
save the record, send it for review, or cancel out of the current revisions.
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.