Annual Exam

The most common type of appointment that you will encounter as an OA is called an Annual Exam. An Annual Exam (or full exam) is a 30 minute appointment during which the doctor completes a comprehensive evaluation of the patient’s entire visual system. Every exam has two portions: a vision portion and a medical portion. During the vision portion the doctor uses several instruments to determine the patient’s refractive error (degree of nearsightedness, farsightedness, astigmatism, and accommodative system) which is then translated into glasses and contact lens prescriptions. During the medical portion, the doctor examines the health of the front surface of the eye (called the anterior), the inside and back of the eye (called the posterior), the intraocular pressure, the muscles that move the eyes, and the pathways (optic nerve) that transmits visual signals to the brain for processing.

There are many different names used to categorize exams based on a variety of demographic and scheduling factors; however, they all have the same basic process with slight variations (except for an InfantSee exam):

EP Exam (which stands for existing patient exam)
Annual/ANNUAL exam (which is also an existing patient, but is labeled differently to indicate that this was an exam scheduled at last year’s exam)
NP Exam (which stands for new patient exam)
MDCR Exam (which indicates that the patient has Medicare insurance)
MDCD Exam (which indicates that the patient has Medicaid insurance)
NP REF Exam (which stands for a new patient exam that was referred to us by another doctor)
SPNDS Exam (which indicates that the patient has special needs to be considered in their care)
InfantSee Exam (which indicates that the patient is under one year of age-our protocols for these exams are quite different than pediatric and adult exams)

As an OA, you have two primary functions during exams: the work up and scribing. The work up is a series of tests and questions that you will perform/ask the patient . Scribing is documenting the doctor’s findings and recommendations in the patient’s chart. Both of these functions are outlined below and will be covered in more depth in the following modules. Before we discuss the workup and scribing, we will briefly go over how to start a chart in the patient record.

Creating an Exam Chart

At Professional Vision Care, we use an electronic health records system (EHR) called Compulink to document everything that occurs during a patient’s visit. Instead of paper charts and filing cabinets, an EHR system uses digital charts stored on a secure server. When a patient comes in for their appointment you will start a new chart in their file. Every patient encounter must have a new chart created for that appointment. A chart is a series of tabs that over the course of the appointment will be filled in with the doctor’s findings and recommendations. The tabs in a chart will vary based on the type of appointment. When you add a chart, rather than add each tab individually, you will select the most appropriate option from of list of preset chart templates.

First, find the patient’s demographic page in Eyecare. Next open up the patient’s file or “doctor bag” (which is like opening up a filing cabinet of all charts that have ever been created for the patient with the most recent chart at the front) by clicking on the Exam icon in the menu bar.

This will bring up the most recent chart that was created for the patient. To add a new chart for the day, click on the Add icon in the upper left corner of the menu bar.

This will bring up the chart template list to select from. There are a lot of options on the template list. For exams, however, you only need to consider three options: Complete Exam, Child Complete Exam, and CL Exam.

Complete Exam: Basic exam template.

Child Complete Exam: Basic exam template with the child hx tab

CL Exam: Basic exam template with the cl tab added and the testing tab removed.

Which option you select will be patient specific. If the patient wears contacts, select the CL exam template. If the patient does not wear contacts and is under 18, select the Child Complete Exam template. If the patient does not wear contacts and is over 18, select the Complete Exam Template.

If you select the wrong template and are missing a tab that you need, don’t worry, you have the option of adding individual tabs to your template at any time.

Here is a video showing how to add a new chart

Now that you know how to start a chart, we can move on to an overview of the work up and scribing.

the work up

A patient work up consists of those tasks that the OA completes with the patient PRIOR to the patient seeing the doctor for their appointment. When a patient comes in for their exam, they are first checked in by the front desk team members, who also verify their vision benefits and medical insurance information. Once the front desk team member has completed all of their check in responsibilities with the patient, the OA will call back the patient and begin the work up (also known as pretesting) for the patient. The work up of exams is different from the workup of an intermediate appointment. In this module we will cover the exam workup only and explore the workup for each type of intermediate appointment in their corresponding modules.

Side Note: If there is a designated Pretester scheduled that day at your office, the OA will check with the Pretester before taking the patient back to see what portions of the work up have already been completed.

The exam work up is made up of four parts: the greeting, initial testing, medical history, and complaints. Here is a look at the four parts of the work up and their individual components.

Greeting

Greet the patient warmly and introduce yourself. “Hi there, (patient name). My name is (your name) and I am assisting Dr (doctor’s name) today, and we are going to get started with your exam.” Be kind and caring, even if you are busy, and communicate a relational and genuine attitude of care. Some folks are a little nervous about doctor’s appointments, and you want to assure them that they are in good hands and can relax.
Initial Testing
Complete the following tests on the patient, explaining to them what you are doing, and documenting the findings as needed in their EHR record:
1. Autorefractor/NCT
2. Retinal Photography
3. Octopus or FDT
Enter the findings from the autorefractor into the phoropter or the patient’s glasses prescription from the prior year, whichever your current doctor prefers
Check visual acuity with patient’s glasses or contact lenses; monocularly (one eye at a time) at distance, binocularly (eyes together) at near.
If the patient is a child, you may need to do a Stereo and Color Test with the patient
Medical History
Verify the patient’s medications and medication allergies, and document in their EHR record
Verify their health history and review of systems, and document in their EHR record
If the patient has Diabetes, ask the patient for information regarding their last A1C and blood sugar readings, who their primary care provider and/or endocrinologist is, and document in their EHR record
Complaints
Determine any patient complaints, checking which insurance is being billed to determine the Chief Complaint
Determine any glasses the patient currently uses, their age and whether they are PAL (no-line-bifocal) or SV (single vision).
If the patient wears contact lenses, complete the additional steps for contact lens wearers, and complete the CL Care Form with the patient

Note: please ensure that you are properly cleaning and disinfecting surfaces between each patient.

Doctor Update

After completing the exam workup, the OA will touch base with the doctor before they head in to see the patient. At this point they will relay all information obtained during the workup, dividing the information into two sections: vision and medical. Here is an example of the type of information you should relay along with the order in which it should be relayed to the doctor.

(Patient Name) is ready to be seen.

Vision Update

They wear (Glasses, Contacts, both, no correction)

For Contacts, they wear (brand) and report (good/poor) comfort

Last glasses are (PAL, SV) from (year)

VAs today were ___ OD, ___ OS, and ___ at near w/(Glasses, Cls, Neither)

Overall they feel that vision is (stable vs. change at distance, computer, near)

Medical Update

Other things going on . . .

Patient reports recent (dryness, floaters, redness, etc) in the (right eye, left eye, both) that started (date). Pt has tried (treatment).

We are also watching patient for (POAG-B, Macular Degeneration, Diabetes, etc)

Pt was recently diagnoses with (hypertension, diabetes, Lupus, etc)

Octopus was (clear, missed spots)

Photos are (complete/unable d/t small pupils)

Note: To help you early on, the above update format is available to print out from the OA helpful things folder so that you can record findings on it to have with you when you speak with the doctor

scribing for the doctor

Now that all of the preparatory tasks have been completed for the patient, you are ready for the doctor to come into the exam room and perform the rest of the exam. Once the doctor enters the room, the primary task of the OA is to “scribe,” which means document in the EHR record, all of the doctor’s findings as they complete the exam. The OA may also be asked by the doctor to assist them in various portions of the exam as needed. Accuracy and attention to detail are VITAL in this role, as every bit of documentation you put in the patient’s medical record is expected to be 100% correct, and can have massive impacts on their treatment.

Scribing involves recording the doctor’s findings during:

Binocularity testing (testing the patient’s ability to track and fuse an object into a single image while looking at it with both eyes)
Refraction and Accommodation Testing (finding a patient’s refractive error along with the finalizing of new glasses)
Contact Lens Evaluation (if the patient wears contact lenses an evaluation of the fit must be completed to make sure they do not cause contact lens related complications)
Anterior and posterior examination and check intraocular pressure (examination of all parts of the eye for signs of ocular disease)

After recording findings the doctor will give the patient their list of recommendations which are used for:

5. Completion of the Plan (List of a patient’s applicable diagnoses each with their own special plan of treatment)

6. Completion of the Routing Tab (billing codes, cl services, instructions for future appointments and eyewear as prescribed by the doctor)

Please complete the Checkpoint Quiz