Once
a patient is selected from the list of Referrals the user is presented with a
page showing four tabs, Encounters, Patient, Problem List, and
Review Comments. The Encounters tab is shown as a default.
Operation Note: You can perform Select, Save and
Cancel operations throughout the application on various tabs and pages. You can
perform the following operations:
·
Click
Save to save any changes.
·
Click
Cancel to return to the list of
Referrals.
·
Click
Select button to display the Patient
Encounter to display.
Navigation Note: Throughout the application you
will be given the opportunity to use navigation buttons. When you are shown a
navigation button you can:
·
Click
Return to Patient’s Encounter List
button to return to the patients encounter list.
·
Click
Cancel to return to the list of
Referrals.
Actions Note: Depending on your user role and
queue that you are working in you may be able to perform actions on the
referral. You may be able to:
·
Click
Send for Review (If in the In
Process or Returned queue.)
·
Click
Send Back to Abstractor
·
Click
Ready to Send (If in the Ready for
Review queue)
Comments Note: Depending on your role and the
queue you are working in you may have the option to add a comment, close a
comment, and save a comment. You may also have the ability to either indicate
that a comment has been resolved and/or approved.
Click
to
add a comment
Click
to
open a comment
Click
to
close a comment
Click
to save and return to the comment
list
You
can mark comments as Resolved by selecting the Resolved check box.
You
approve changes for a comment by selecting the Approved check box.
Encounters Tab
This
displays the Patient Encounters panel
listing the patient encounters relevant to the registry. The fields included are Encounter Date, Last
Updated Date, and Updated By. The last
updated date and updated by fields will be updated whenever someone edits data
anywhere within the encounter.
Click on
any of the column names to sort the columns from ascending to descending order
alphabetically or numerically.
Click Select to choose a patient Encounter to
display five tabs:
Provider Tab
Displays the Encounter Information;
Provider Information; Address; Phone; and Other.
The user can not edit the fields on the form.
Chief Complaint Tab
Encounter Information
panel: Facility
name is displayed and the date of the encounter.
Chief Complaint panel: The user may enter text and then click the Save button to save the changes to the
record; Cancel to abort the changes;
or Action Buttons depending on status
and role.
Neurological
Conditions panel: Choose the check box that
describes the patient’s neurological condition(s). One or more check boxes can be chosen. Enter
text in the Comments box to further describe the patient’s condition.
Exam Tab
Encounter Information panel: Facility name is displayed and the date of the encounter.
Eye Exam panel:
·
Complete
the eye exam for both the Right Eye
and Left Eye by selecting the values
from the drop down lists, on screen choices, and comments fields. To expand the
individual exam panels, select Yes
for Was test performed?
·
If
adding an Imaging/Ancillary method
select the method from the available list and enter the date (optional), then
click Add.
·
Prosthetic Devices
Ordered
panel: Check one or more boxes
·
Visual Functioning
Questionnaire panel: Select in drop-down list
·
Eye Exam Comments panel: The user may enter text .
Click
one of the following buttons:
·
Save button to save the changes to the
record;
·
Cancel to abort the changes;
·
Action Buttons depending on status
and role.
·
Return to Patient’s Encounter List
Diagnosis
(ICD Codes) Tab
Encounter Information panel: Facility name is displayed
and the date of the encounter.
Diagnosis panel: Eye injury ICD codes are
displayed for the encounter.
Referred
to/currently in Vision Rehabilitation selection panel: Select Yes or No.
Comments panel: You may enter text in the Comments box.
Click one of the
following buttons:
·
Save button to save the changes to the
record;
·
Cancel to abort the changes;
·
Action Buttons depending on status
and role.
·
Return to Patient’s Encounter List
Procedures (ICD &
CPT4 Codes) Tab
Encounter Information panel: Facility name is displayed
and the date of the encounter.
Procedures panel:
·
Diagnostic Procedure Code ICD codes are displayed if available.
·
Procedure Code (CPT-4) is displayed if available.
Comments panel: The user may enter text in the box
Click
one of the following buttons:
·
Save button to save the changes to the
record;
·
Cancel to abort the changes;
·
Action Buttons depending on status
and role.
·
Return to Patient’s Encounter List
Patient Tab
Displays
the Patient Name; Patient Information; Address; Phone; Email Address; Next of
Kin and Other information for the patient.
·
If
a field has a text box the field can be edited and saved.
Problem List Tab
Displays Active Problems and Inactive Problems. The data displayed
in this tab is not editable (i.e.,
read only)
Review Comments Tab
This tab
contains comments from the medical reviewer for the Abstractor of the referral.
If there are no comments to display a message will display stating that there
are ‘No review comments for this referral’.
If
comments are shown then Click Select for
the Comment and Panel Name to display. The panel and comment is displayed. A
check box is shown to indicate if the comment was Resolved
and Approved.
NOTE: Records in the “Ready to Send”
queue can be RETURNED to the abstractor if additional editing is required.