Techbook

Book

Chapters

Chapter

All Patients New and Existing

All Patients New and Existing

New and Existing

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Choose the exam layout

Review the medical history tab with the patient to include:

9 Exceptions

Ocular history Edit
Review of systems Edit
Family history Edit
Tobacco status Edit
Pneumonia, Flu, and Covid vaccination status Edit
PCP, endocrinologist and referring doctor Edit
Diabetic patients: most recent blood sugar value and time taken Edit
A1c value if available and when it was done. Be sure to initial date reviewed Edit
Check fall risk for patients 65 years and older Edit

Tech tab: add the reason for the visit

4 Exceptions

For a new patient ask the patient and add who referred them Edit
For an existing patient check the plan (diagnoses) from the previous exam. Edit
Include any testing that was ordered Edit
Refer to the plan from the last visit for any medication changes and add to ocular medications with the correct start date and directions. Edit

Medications:

3 Exceptions

For new patient only: to add systemic medications go to Erx to upload. if unable to, each medication must be added with a route and start date. all supplements need to be entered as well with the route and start date Edit
For existing patients: review the medications list on file and make changes if needed. Edit
Be sure to initial review Edit

Document Allergies/Sensitivities