Difference between revisions of "Eye Exam"

From OpenEMR Project Wiki
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Additionally, within each section of the clinical portion of the form, there are links to upload new images or  view the current images.   
Additionally, within each section of the clinical portion of the form, there are links to upload new images or  view the current images.   


There is a size limit that each server can handle, set during the installation process.  There is no limitation on the type of files that you can store:  images, movies, audio files, PDFs, etc.
There is a file size limit that each server can handle, set during the installation process.  There is no limitation on the type of files that you can store:  images, movies, audio files, PDFs, etc.


= Impression/Plan =
= Impression/Plan =

Revision as of 19:35, 21 March 2016

These Wiki documents will provide an in depth look into the OpenEMR: Eye Exam form, from installation to usage.


General overview

The Eye Exam is an OpenEMR form for ophthalmology and optometry. It is feature rich, yet remarkably simple to use. It is written to mirror the workflows of the provider. Given that workflows vary from provider to provider, the Eye Exam is adaptive and seeks to learns the preferences of each provider, based on how it is used by a given doctor. It's like it is alive. At least that is how we want it to appear. It is listening to what you do as you do it, and learns. The more you use it, the more it learns. The more it learns, the more feedback it can give you.

The Eye Form is one page. No need to click around looking for data - it is all in front of you.

When a provider documents something, it is stored. Done. No submit button. No clicks. Just move on to the next patient.

And how can a provider document? Text/Shorthand/Draw? Yes, yes and yes.

  • Text input is boring, but the standard in EHRs. Better get a scribe if you want to remain productive and plan to use this technique exclusively.
  • Drawing. Well, the technology is getting better but it is not the best way to complete a whole exam. The Eye Exam has draw sections for each area because, as eye doctors, we like pictures. Use a pen, a mouse or a touch screen. It's all good when it comes to this form.
  • Shorthand. To the non-ophthalmologist/optometrist, this is total Greek. But to eye doctors, this is "totally, outrageously awesome". It turns your chicken-scratch into pure prose at the speed of your brain.
  • Old Records are always available, on the one page still, to compare or pull-forward into the current chart. And you can pull forward one clinical section, or all of it.

What does the form do with your clinical input, beside storing it? Is it really alive?

  • It integrates with the OpenEMR Care data management plans.
  • It recognizes diseases and translates them into diagnostic codes.
  • It builds your Impression Plan.
  • It suggests a billing code for the visit.
  • It builds your routing slip/Fee Sheet.

Install

At the time of this article (11/11/15), the Eye Exam form has not been through a code review and is not part of the base installation. Until then, the Eye Exam form can be installed like any other OpenEMR form, but you will have to add these files into your library area if they are not already present:

  • /openemr/library/css/pure-min.css
  • /openemr/library/css/bootstrap-3-2-0.min.css
  • /openemr/library/css/font-awesome-4.2.0/css/font-awesome.css
  • /openemr/library/js/jquery.min.js
  • /openemr/library/js/bootstrap.min.js

The most current files can be found in the repository located here:

https://github.com/ophthal/openemr_2.git

There is a demo server located at:

http://demo.open-emr.org:2108/openemr
Username: admin Password: pass

We created a unique style sheet should you wish to use it.

Access it via the left menu, Administration -> Globals and choose the Theme style_tan_no_icons.css.

Our Style Sheet

Documentation/Display Options

Different users interact with EMRs in different ways. Sometimes we want to draw a picture, other times we need to write out our findings in detail. With the OpenEMR: Eye Exam, you can use a number of different methods to document your exam.

  • TEXT: fill in anatomic-specific fields with text by typing
  • PULL FORWARD: pull-forward values from an earlier encounter
  • DRAW: draw your findings
  • QUICK PICKS: select from a dynamic list of clinical findings
  • SHORTHAND: a rapid method for entering findings via the keyboard based on traditional shorthand used with paper charts.
  • DICTATION: users facile with the Shorthand module and with dictation software can dictate their notes in shorthand format directly into the Shorthand zone, or directly into the fields with the aid of their mouse to navigate through the EMR.
  • DEFAULTS: populate the form with default values.


NOTE: Active Charting vs. READ-ONLY mode:

Right Panel


Text

Using the tab key or mouse you can select a field and type in your findings. Tab or click to move through the fields. This is the typical way we interact with web based forms, and perhaps the most common reason clinicians fail to move from paper to electronic charts...

Draw

Each portion of the form has a Draw Component. Choose the color and size and Draw away. Redo and Clear Functions extend the range of this feature. As the tools for drawing via web-based applications improve, this method of charting, which is essentially the same as using paper, will improve.

Quick Picks

Commonly used findings can be clicked on to fill the appropriate field/s on the form. Currently the list of items in the Quick Pick lists is static. Development is underway to build these lists dynamically on a per provider basis, so a provider's frequently used terms will appear over time.

KeyBoard (Shorthand)

Introduction

What if you could document electronically using your shorthand?
We converted a standard ophthalmic record and commonly used shorthand terms into Eye Shorthand, an electronic lingua franca oculī.
Using this shorthand method, all findings are entered in a single text field,

and the EMR fields are automatically filled.


Paper vs. EHR:
You know what RUL: 2mm ptosis means.
With a typical EHR, you need to find and click on the field for the right upper lid and type in 2mm ptosis.
Then click on the next field, or maybe even tab to it, and type your findings for the next field. And on it goes. If this is your preferred way to document, you can do this TEXT method with this form.

Consider another example: Right C/D 0.6Vx0.4H with inferior notch, left C/D 0.5?
OK, find the correct field (right cup) to click. Enter the appropriate text, 0.6Vx0.4H with inferior notch. Then tab or click to the next field. Type 0.5.

How can we speed up this process?

Look at this example in shorthand, based on a simple structure: Field.text;Field.text;Field.text

rcup.0.6Vx0.4H w/ inf notch;lcup.0.5

Type this shorthand text into the Keyboard Entry area in the form, and the fields are automatically filled.
Done. No extra clicks.
Even a slow typist will find the Eye Exam Shorthand can speed up EHR documentation time.
It is easy to learn.
The Fields and text parts look just like our handwritten shorthand!
Type the abbreviation for a clinical field, a period/fullstop, followed by your finding, in your shorthand.
If your shorthand doesn't match the base install's shorthand, your shorthand text will be displayed.
It is easy to add your shorthand. If you need customization, add your unique style of shorthand to your local copy of /forms/eye_mag/js/js_my_base.js
Consider sharing your shorthand back to the community for future users.

The explanation below centers around four lines of typing which document normal findings and more than 40 different clinical issues.
That's a lot to document and one mighty complicated patient!
Many more issues than we would see on a routine day with routine patients, but it could happen...
Documenting this many findings would take a little bit of time on paper, and a lifetime in an EHR.
With the openEMR Shorthand, the average typist can do it in less than a minute.



Go ahead and paste the lines below into a test patient's chart. Fiddle with them.

D;bll.+2 meibomitis;rll.frank ect, 7x6mm lid margin bcc lat.a;bul.2mm ptosis;rul.+3 dermato.a; bc.+2 inj;bk.med pter;rk.mod endo gut.a;bac.+1 fc, +1 pig cells; bd.+2 bowtie pallor;rc.0.6Vx0.4H w/ inf notch;lc.0.5;rmac.+2 BDR, +CSME;lmac.flat, tr BDR;v.+PPDR, ++venous beading;rp.ht 1 o,no vh; scDist;5.8ix 1rht;4.10ix;6.6ix;2.15xt;8.5ix;ccDist;4.5ix;5.ortho;6.ortho

Right Panel


Within openEMR: Eye Exam there are detailed instructions for each section.
If you are already an eyedoc, this is simple and intuitive.


Key point: Only use the "D;" once and only at the start. It is very powerful. The D; tells Eye Exam to ERASE EVERY field and replace them with your default values (defined in /eye_mag/js/js_my_base.js). D; will replace everything with its default value.

Basic Structure

Usage: field.text(.a)(;)

where:

Field is the shorthand term for the clinical field.
text is the complete or shorthand data to enter into this field.
field and text are separated by a "." period/fullstop.
The trailing ".a" is optional and will append the text to the data already in the field, instead of replacing it.
The semi-colon ";" is used to divide entries, allowing multiple field entries simultaneously.
The semi-colon separates entries and cannot be used within a text field.
After pressing Enter/Return, the data is submitted.


Right Panel



External: Shorthand Walk Through

Keyboard Entry

D;bll.+2 meibomitis;rll.frank ect, 7x6mm lid margin bcc lat.a;bul.2mm ptosis;rul.+3 dermato.a

Sh ext.png




This line will be recorded in OpenEMR: Eye Exam as:


Sh ext EMR.png


This is how this shorthand will appear in a Printable Report:

Sh ext report.png

External: Field Codes and Shorthand/Abbreviations

Clinical FieldShorthand* FieldExample Keyboard Entry**EMR: Field text
Default valuesD or d d;
D;
All fields with defined default values are erased and filled with default values.
Fields without defined default values are not affected.
Right Browrb or RB rb.1cm lat ptosis
rb.med 2cm SCC
1cm lateral ptosis
medial 2cm SCC
Left Browrb or RB rb.loss of lat brow follicles
lb.no rhytids from VIIth nerve palsy
loss of lateral brow follicles
no rhytids from VIIth nerve palsy
Both Brows/Foreheadfh or FH
bb or BB
fh.+3 fh rhytids
BB.+3 glab rhytids
+3 forehead rhytids
+3 glabellar rhytids
Right Upper Lidrul or RUL RUL.1cm lat ptosis
rul.med 2cm SCC
1cm lateral ptosis
medial 2cm SCC
Left Upper Lidlul or LUL LUL.1cm lat ptosis
lul.med 2cm SCC
1cm lateral ptosis
medial 2cm SCC
Right Lower Lidrll or RLL rll.1cm lat ptosis
rll.med 2cm SCC
1cm lateral ptosis
medial 2cm SCC
Left Lower Lidlll or LLL lll.0.5cm lat ptosis
LLL.med 2cm SCC
1cm lateral ptosis
medial 2cm SCC
Right Medial Canthusrmc or RMC rmc.1cm bcc
RMC.healed dcr scar
1cm BCC
healed DCR scar
Left Medial Canthuslmc or LMC lmc.acute dacryo, tender w/ purulent drainage
lmc.1.2cm x 8mm mass
acute dacryo, tender with purulent drainage
1.2cm x 8mm mass
Right Adnexarad or RAD rad.1.8x2.0cm bcc lat
RAD.healed DCR scar
1cm BCC
healed DCR scar
Left Adnexalad or LAD lad.1cm lacr cyst protruding under lid
LAD.1.2cm x 8mm mass
1cm lacrimal cyst protruding under lid
1.2cm x 8mm mass

*case insensitive
**The default action is to replace the field with the new text.
Adding ".a" at the end of a text section will append the current text instead of replacing it.
For example, entering "4xL.+2 meibomitis.a" will append "+2 meibomitis" to each of the eyelid fields, RUL/RLL/LUL/LLL.



Anterior Segment: Shorthand Walk Through

Keyboard Entry

D;bc.+2 inj;bk.med pter;rk.moderate endo gut.a;bac.+1 fc, +1 pig cells

Sh antseg.png



This line will be recorded in OpenEMR: Eye Exam as:


Sh antseg EMR.png


This is how this shorthand will appear in a Printable Report:

Sh antseg report.png



Anterior Segment: Field Codes and Shorthand/Abbreviations

Clinical FieldShorthand* FieldExample Keyboard Entry**EMR: Field text
Default valuesD or d

d;

D;
All fields with defined default values are erased and filled with default values.
Fields without defined default values are not affected.
ConjunctivaRight = rc
Left = lc
Both = bc or c

rc.+1 inj

c.med pter
"+1 injection" (right conj only)
"medial pterygium" (both right and left fields are filled)
CorneaRight = rc
Left = lc
Both = bk or k

rk.+3 spk
k.+2 end gut;

rk.+1 str edema.a
"+3 SPK" (right cornea only)
"+2 endothelial guttatae" (both cornea fields) AND "+1 stromal edema" (appended to Right cornea field)
Anterior ChamberRight = rac
Left = lac
Both = bac or ac

rac.+1 fc

ac.+2 flare
"+1 flare/cell" (right A/C field only)
"+2 flare" (both A/C fields)
LensRight = rl
Left = ll
Both = bl or l

RL.+2 NS
ll.+2 NS;

l.+3 ant cort spokes.a
"+2 NS" (right lens only)
"+2 NS" (both lens fields) AND "+3 anterior cortical spokes" (appended to both lenses)
IrisRight = ri
Left = li
Both = bi or i

bi.12 0 iridotomy
ri.+2 TI defects.a;

li.round
"12 o'clock iriditomy" (both iris fields)
", +2 TI defects" (right iris field AND "round" (left iris field only)
GonioRight = rg
Left = lg
Both = bg or g

rg.ss 360

lg.3-5 o angle rec
SS 360
3-5 o'clock angle recession
PachymetryRight = rp
Left = lp
Both = bp or p

lp.625 um

p.550 um
"625 um" (left pachymetry field)
"500 um" (both pachymetry fields)
Schirmer IRight = rsch1
Left = lsch1
Both = bsch1 or sch1

rsch1.5mm

sch1.> 10mm/5 minutes
"5mm" (right field only)
> 10mm/5 minutes" (both fields)
Schirmer IIRight = rsch2
Left = lsch2
Both = bsch2 or sch2

rsch2.9 mm

sch2.> 10mm/5 minutes
"9 mm" (right field only)
> 10mm/5 minutes" (both fields)
Tear Break-up TimeRight = RTBUT
Left = LTBUT
Both = BTBUT or tbut
tbut.> 10 seconds
Rtbut.5 secs;ltbut.9 seconds;
"10 seconds" (both fields)
"5 seconds" (right) AND "9 seconds" (left)


*case insensitive
**The default action is to replace the field with the new text.
Adding ".a" at the end of a text section will append the current text instead of replacing it.
For example, entering "bk.+2 str scarring.a" will <class="underline bold">append</class> "+2 stromal scarring" to both the right (rc) and left cornea fields (lc).


External Shorthand Abbreviations:

The following terms will be expanded from their shorthand to full expression in the EMR fields:

Enter this:Get this:
infinferior
supsuperior
nasnasal
temptemporal
medmedial
latlateral
dermatodematochalasis
w/with
laclaceration
lacrlacrimal
dcrDCR
bccBCC
sccSCC
sebcasebaceous cell
trtrace




Retina: Shorthand Walk Through

Keyboard Entry

D;bd.+2 bowtie pallor;rc.0.6Vx0.4H w/ inf notch;lc.0.5;rmac.+2 BDR, +CSME;lmac.flat, tr BDR;v.+PPDR, ++venous beading;rp.ht 1 o,no vh;
Sh retina.png


This line will be recorded in OpenEMR: Eye Exam as:


Sh retina EMR.png


This is how this shorthand will appear in a Printable Report:

Sh retina report.png


Retina: Field Codes and Shorthand/Abbreviations

Clinical FieldShorthand* FieldExample Keyboard Entry**EMR: Field text
Default valuesD or d d;
D;
All fields with defined default values are erased and filled with default values.
Fields without defined default values are not affected.
Disc Right = rd
Left = ld
Both = bd or d
rd.temp pallor, PPA
c.NVD at 5 o
"temporal pallor, PPA" (right disc only)
"NVD at 5 o'clock" (both right and left disc fields)
CupRight = rc
Left = lc
Both = bc or c
rc.0.5 w/ inf notch
c.temp scalloping, 0.5.a;rk.+1 str edema.a
"+3 SPK" (right cornea only)
"temporal scalloping, 0.5" (appended to both cup fields)
MaculaRight = rmac
Left = lmac
Both = bmac or mac
rmac.central scar 500um
mac.soft drusen, - heme.a
"central scar 500um" (right macular field only)
"soft drusen, - heme" (appended to both macular fields)
VesselsRight = rv
Left = lv
Both = bv or v
RV.1:2, +2 BDR
lv.+CSME w/ hard exudate sup to fov (300um);v.narrow arterioles, 1:2.a;
"1:2, +2 BDR" (right vessels only)
"+CSME with hard exudate superior to fovea (300um)" (left vessel field only) AND "narrow arterioles, 1:2" (appended to both vessel fields)
PeripheryRight = rp
Left = lp
Both = bp or p
rp.12 0 ht, no heme, amenable to bubble;
bp.1 clock hour of lattice 2 o.a;li.round
"12 o'clock horseshoe tear, no heme, amenable to bubble" (right periphery field)
"1 clock hour of lattice 2 o'clock" (appended to both periphery fields)
Central Macular ThicknessRight = rcmt
Left = lcmt
Both = bcmt or cmt
rcmt.254
cmt.flat
254 (right CMT only)
flat (both CMT fields)


*case insensitive
**The default action is to replace the field with the new text.
Adding ".a" at the end of a text section will append the current text instead of replacing it.
For example, entering "bk.+2 str scarring.a" will <class="underline bold">append</class> "+2 stromal scarring" to both the right (rc) and left cornea fields (lc).



Retina Shorthand Abbreviations:

The following terms will be expanded from their shorthand to full expression in the EMR fields:

Enter this:Get this:
infinferior
supsuperior
nasnasal
temptemporal
medmedial
latlateral
csmeCSME
w/with
bdrBDR
ppdrPPDR
hthorsheshoe tear
abair bubble
c3f8C3F8
mamacroaneurysm
trtrace
miasmicroaneurysm
pedPED
1 o 1 o'clock
2 o2 o'clock
3 o 3 o'clock
4 o 4 o'clock
5 o 5 o'clock
6 o 6 o'clock
7 o 7 o'clock
8 o 8 o'clock
9 o 9 o'clock
10 o 10 o'clock
11 o 11 o'clock
12 o 12 o'clock
macmacula
fovfovea
vhvitreous hemorrhage




Neuro-Physiology: Shorthand Walk Through

Keyboard Entry

scDist;5.8ix 1rht;4.10ix;6.6ix;2.15xt;8.5ix;ccDist;4.5ix;5.ortho;6.ortho

Sh neuro.png

This line will be recorded in OpenEMR: Eye Exam as:

Sh neuro EMR1.png
Sh neuro EMR2.png


This is how this shorthand will appear in a Printable Report:

Sh ext report.png


Neuro-Physiology: Field Codes and Shorthand/Abbreviations

Clinical FieldShorthand* FieldExample Keyboard Entry**EMR: Field text
Default valuesD or d

d;

D;
All fields with defined default values are erased and filled with default values.
Fields without defined default values are not affected.
Without correction at DistancescDist scdist; scDIST is selected for ensuing values.
With correction at DistancescDist ccdist; ccDIST is selected for ensuing values.
Without correction at NearscNear scdist; scDIST is selected for ensuing values.
With correction at NearscNear scdist; scDIST is selected for ensuing values.

*case insensitive
**The default action is to replace the field with the new text.
Adding ".a" at the end of a text section will append the current text instead of replacing it.
For example, entering "bk.+2 str scarring.a" will <class="underline bold">append</class> "+2 stromal scarring" to both the right (rc) and left cornea fields (lc).


Neuro Shorthand Abbreviations:

The following terms will be expanded from their shorthand to full expression in the EMR fields:

StrabismusEnter this:Get this:
ExophoriaxX
Intermittent Esotropiaie or e(t)E(T)
EsoptropiaetET
EsophoriaeE
Intermittent Exotropiaix or x(t)X(T)
ExoptropiaxtXT
HyperphoriahH
Intermittent HypertropiaH(T)H(T)
Hypertropiarht
lht
RHT
LHT
HypotropiahytHyT


Side Panel

This form has a built-in panel to display PMSFH and ROS data.

Top half.png
Right Panel

The Panel slides in and out from the right margin either via the menu (VIEW->PMSFH Panel)

PMSFH Menu.png

or by clicking on the Panel icon Panel.png, located in the top-right corner of the PMSFH section:

PMSFH.png

Clicking either the Panel Icon a second time, the "X" at the top of the Right Panel itself or by selecting the VIEW-> Right Panel on the menu, and the panel will slide to the right and disappear.

Full Screen Mode

If you are working in the framed mode of openEMR, you can break out into fullscreen mode by clicking on the "plus" icon at the top right corner of the page. The Eye Exam in the bottom frame will close and the billing module will replace it. A new window will open with the Eye Exam form. Pop-up blockers must be disabled for this feature to work reliably. You must authorize this new window to WRITE data to the database, otherwise it will open in READ-ONLY mode.


Application-style Menu Bar

Chief Complaint and History of Present Illness

The CC (Chief Complaint) and HPI (History of Present Illness) are standard fields present in any medical document. This form allows the user to document up to three separate complaints, CC1, CC2, CC3, with corresponding HPIs.

HPI PMSFH.png

In the US, to reach a higher coding level, you must document a detailed HPI. This requires documenting and commenting on the status of 3 chronic or inactive problems or document 4 or more elements which comprise the current HPI. Either complete the three Chronic fields, or include the four HPI elements in your narrative, or tap the database icon to display helper fields:

HPI detailed.png

PMSFH/ROS

Visions/Refraction Panels

IOP/Amsler/CVF/Pupils

External

Anterior Segment

Retina

Neuro-Physiology

Images and OpenEMR

Images can be uploaded into openEMR directly via the documents (Patients/Client->Summary and click the Documents link) or via the Fax/Scan interface (Administration->Fax/Scan) if you have configured it.

When the Eye Form is first used, you will notice that multiple Imaging categories are automatically created, such as visual fields, OCT, etc. You can edit these names or add new categories using the Administration->Practice Documents link.

Additionally, within each section of the clinical portion of the form, there are links to upload new images or view the current images.

There is a file size limit that each server can handle, set during the installation process. There is no limitation on the type of files that you can store: images, movies, audio files, PDFs, etc.

Impression/Plan

The Impression Plan can be entered manually or by using the Impression/Plan Builder.

The Builder extracts potential diagnoses to include in your Impression/Plan from the Past Ocular History, the Past Medical History and the physical exam findings. If your openEMR setup includes codes such as ICD-10 and CPT codes, the Impression/Plan Builder will utilize these. If you plan to use openEMR Ophthalmology to perform your clinic's billing functions, it is advisable to choose the correct codes when a POH or PMH item is added initially. Not only will the Impression Plan Builder make full use of these codes but the Coding Engine will submit these codes to the Fee Sheet for billing.


For returning patients, the prior Impression Plan can be carried forward into the current visit where it can be directly updated with your new findings.

Printable Report

Conclusions =