Ophthalmology
Overview
Figure 1: The Visual Acuity Box
To newly record a patient's visual acuity (Figure 1), start by entering the date. You can use the calendar button for easy selection if desired. Select any recorded data from the relevant drop down lists, remembering that the box on the left is reprasentative of the patient's right eye, and vice versa. To overwrite a pre-existing record, simply click the Save button. To create a new record, click the New button. You can then browse through existing records using the View drop down list by date.
Figure 2: The Past Medical History Box
The Past Medical History Box (seen in Figure 2) shows a record of the patient's general medical history, as recorded also on the Medical History Page in the patient record (accessed from the left side menu). You can add a medical history item by clicking the Add History item. Items recorded from the Medical History Page will also show up in this box.
Figure 3: Adding a New Medical History Item
To add a new medical history item, first click on the Add History button (as mentioned above). The box shown in Figure 3 will appear. Indicate the item status using the drop down list provided. If relevant, select a side. Enter a brief description of the item and indicate the duration. For the History Type, select whether this item is relevant to the patient's generic medical history or is specifically ocular. In the comments box, give details of the medical history item and click the Add button to save the entry.
Figure 4: The Diagnosis History Box
When you start typing a diagnosis into the Diagnosis History text box (Figure 4), a list of autofill suggestions will appear below from which you can select the relevant diagnosis. The date will default to today's date, however this can easily be changed by typing over it, or selecting a new date from the calendar. Click Add and you should see the new diagnosis in the table below.
To add a diabetic retinopathy record, select Diabetic Retinopathy from the Forms drop down list and click Go.
Figure 5: The Diabetic Retinopathy Form
You can then enter the screening results using the drop down lists for each of the sections: Malculopathy, Retinopathy and Retino Stage (Figure 5). You may also enter any other observations in the text box below. To add the record, click the Save button.
Figure 6: The Eye Surgery Box
When recording a surgery (Figure 6), first select whether both, just the left or just the right eye(s) were operated on. Select the type of surgery and the date on which it occured. Click Save and you should see your new surgery record listed in the table below.
Figure 7: The Past Ocular History Box
The Past Ocular History Box (Figure 7) contains medical history specific to the eyes. To add a new record, click Add History.
Figure 8: Adding an Ocular Medical History Item
Adding an Ocular Medical History Item (Figure 8) is just like adding a normal one (Figure 3, above). The only thing to make sure of is that you select Ocular from the History type drop down list.
Figure 9: The Notes Box
Progress notes can be added to a patient's opthalmalogy record and are recorded in Notes box (as shown in Figure 9). To add a new note, simply click the Add Note button. You can then edit or append notes as required, using the buttons provided at the top of the box. To view a note, simply click on it. You can view multiple notes at a time using the Show [#] Notes drop down list.
Figure 10: Adding a New Progress Note
In the Add New Progress Note screen (Figure 10), you can enter an opthalmology progress note like you would do as for a regular progress note, or as you type an MMEx message. Select a reason for contact from the drop down list at the top. Previously given reasons should appear in the drop down list for easy selection, alternatively you can select the 'Other' option from the list and type a new reason into the text field that appears. To add the note, click the Save button.
Figure 11: The Uploaded Files Box
Various files can be uploaded and stored against a patient's opthalmology record (Figure 11). To store a new file, select the type of file from the list of buttons at the top of the box (Referrals, Keratometry, Letters, Documents and Images) and click on the Add button.
Figure 12: Uploading a New File
The New File Upload Box (Figure 12) will show up to three fields. Firstly, a subject field. This is not required and if left blank will be entered as the name of the uploaded file. Secondly, for Keratometry and Image uploads, you will presented with a Type drop down box from which you will need to select the appropriate option. Lastly, click on the Browse... button to locate the file you wish to upload from your computer and click Upload.
Sending Referrals
To send a referral, first click on the Referrals tab and click Add Referral.
Figure 13: The New Referral Screen
Type the name of the doctor you are referring the images to into the Refer to box and select it from the drop down list that will appear from the box. The name should then appear directly below.
Select the priority from the drop down list and add any comments, then click Send.
Figure 14: A referral listed in the table
The referral will appear in the MMEx inbox of the person or organisation that you sent it to, where they can review the patient's ophthalmology record.
Receiving Referrals
When sent an ophthalmology referral, it was show in your MMEx inbox. To open it, simply click on it.
Figure 15: A newly received referral in the MMEx inbox
At the bottom of the referral message, click on the Click here to review referral link to go to the patient's opthalmology record.
Figure 16: Viewing the referral message
Towards the bottom of the opthalmology screen you can find the details of the referral listed in a table. To add review details, click the Review button.
Figure 17: The patient's referral listed on the ophthalmology screen
In the box that appears, select the time period for the next review and the location for the review from the drop down lists. Enter any other relevant notes into the text box provided and click Send.
Figure 18: Entering review details
The review will then show in the Reviews table at the bottom of the opthalmology screen.
Figure 19: The review listed on the patient's ophthalmology record