Complaint Tab

Brief comments about some of the fields on this tab follows:

Accompanied By: If the patient is accompanied by someone in the examination room, obtain the full name(s) of those individuals – especially if the patient is a minor or under the care of someone else.

Relationship: If the patient is accompanied by someone, describe the relationship of the individual(s) to the patient. Use items from the pull-down menu when possible. If you can’t find a suitable choice, free-text the relationship (“Caretaker” is not available in the pull-down)

Translator: Provide the name of the translator, as well as the language being translated.

Last Visit PCP: Document – using items from the pull-down menu – when the patient last saw their primary care provider (PCP).  If they don’t remember the exact date, get them to commit to a month/year, or even a year if it was more than a few years ago. You can also use the drop-down menu to roughly specify when they were last seen by their PCP.

PCP: Using the “Lastname Firstname” format, document the name of the patient’s primary care provider. Or use the drop-down menu to find the names of local providers. Do not include titles (“Dr.”, MD, etc.) in your entry. If your patient doesn’t remember the name of their PCP, document the city and state where they were seen. If we need prior medical information for the patient, we will have a better chance of finding it.

Last Eye Exam: Document – using items from the pull-down menu – when the patient last saw their eye care provider (ECP)

Eye Exam By: Using the “Lastname Firstname” format, document the name of the patient’s eye care provider (ECP). Or use the pull-down menu to find the names of local providers. Do not include titles (“Dr.”, OD, etc.) in your entry. If your patient doesn’t remember the name of their ECP, document the city and state where they were seen (“WalMart, Topeka, KS”). If we need prior eye care information for the patient, we will have a better chance of finding it.
If the patient was seen in one of our clinics, take the time to determine and record their doctor’s name. Don’t just record “AECC”

Complaint History: Create a new grid entry for each visit. Use this entry to record the patient’s primary and secondary complaints. Make sure that your primary complaint is medical if appropriate, and vision related if appropriate (based on the patient’s insurance). In either case, ensure that you ask about vision related problems at both distance and near, and document whether those problems were with or without glasses (“No D blur with Rx, No N blur without Rx”, for instance). For every issue reported by the patient, expand the history as appropriate.
Again, record all information about the primary complaint or complaints followed by all information about the secondary complaint or complaints in this grid entry. Only one grid entry is necessary per visit.
Don’t use the minus sign (“-“) in your documentation, as it can often be overlooked. Use the word “No” instead.

Medication Tab

Information about entering patient medications and allergies is described below. Note that you will learn more about a system call “SureScripts” later. SureScripts allows you to pull information about patient medications from pharmacies who are part of the SureScripts system.

Medications: Enter current patient medications in this grid. Click “No Meds” if the patient is taking no medications. Click “Medication List” to see a list of all medications that have ever been entered for the patient, regardless of whether they are currently taking them or not. Click “Current Meds” to see a list of all patient medications that do not have an associated stop date.

If a medication is already recorded, there is no need to record it again. Confirm that it is still an active medication with the patient, update any other information about the medication as appropriate, and move on.

Allergies: Enter patient allergies in this grid. Indicate what happened when they experience their allergic reaction in the reaction box (“rash”, “itchy”, “upset stomach”, etc.). Click “NKDA” to indicate that the patient has “No Known Drug Allergies”. Click “Active” to see a list of all current allergies.

If an allergy is already recorded, there is no need to record it again. Confirm that it is still an active allergy with the patient, update any other information about the allergy as appropriate, and move on.

ROS Tab

Use the Patient History Form that the patient fills out to help complete this tab. Fill in all pertinent positives and then left-click on the gray area to the left of the screen and select “Assign Normal Values” to complete all other items in the list.

In filling out pertinent positives, it’s generally not necessary to indicate what medication the patient is taking for a condition (that information can be located on the Medication tab, and you should make sure that the medications and conditions reported in the ROS make sense; if they don’t, you need to make them make sense by asking additional questions). Also, unless you have performed a test that somehow measures patient compliance, don’t record compliance or non-compliance. Finally, when recording dates for the onset of conditions (which you should always do for diabetes and hypertension), make sure to record the diagnosis date in absolute terms – “T2D since 2010”. “HTN since 1999”. Don’t use “HTN for 3 years”.  Using an absolute date allows you to accurately forward the data in the future.  And be consistent in how you record this information:  “T2D since 2011”, “HTN dx: 2022” isn’t consitent.  Consistency will help you more quickly review the information in the future

Of course, like all of the patient history, these guidelines are for a basic history. If your examination makes you suspect something that requires further digging into a patient’s history, then start digging.

Patient medications should be recorded on the Medications tab, and don’t need to be repeated here. Additionally, don’t specify whether the patient is compliant or not, unless you have a way of independently verifying their compliance.

SMBS/HgbA1c: Don’t use this section to record the patient’s historical data on diabetes monitoring. This section is used to order these tests.

Surgical History: Record any pertinent patient surgeries in the section, including date, eye and surgeon (if known) for eye surgeries. If the patient has had no surgeries, click the “No Surgery” button to indicate that as appropriate. Surgeries only need to be entered once in this grid; if it’s already recorded, don’t record it again.

Vital Signs: Finally, record the patient’s blood pressure in this grid, located at the bottom of the tab.

Health Hx Tab

The Health Hx tab has five sections – Ocular, Personal Medical, Family, Social, and Tobacco Use. Of these five, you will routinely fill out three of them.

Ocular: Click on the blue “Grid” in the upper right corner of this section. This provides a list of questions about the patient’s ocular history that should be answered for every patient. Check “Yes” or “No” for each of these conditions as appropriate, adding further information as indicated.

Family: Click on the blue “Grid” in the upper right corner of this section. This provides a list of questions about the patient’s family history that should be answered for every patient. Check “Yes” or “No” for each of these conditions as appropriate, adding further information as indicated. You can specify who in the family has the specified condition under “Relationship”; add additional family members with a specified condition in the “Notes”. Remember to constrain your responses to parents, grandparents, and siblings – we don’t need to record information about cousins, aunts, etc. on a routine basis (however, consider digging further if you suspect a genetic condition)

Tobacco Use: Click on the blue “Grid” in the upper right corner of this section and select the most appropriate response for this patient. Add additional information as necessary.
The Personal Medical section should never be used (this information is currently recorded in the ROS tab, but will one day transfer to this area), and the Social section is used when indicated.