Having a clear history of symptom onset or how an injury occurred helps in identifying possible life-threatening conditions.
Description: Discover the daily workflow of an ophthalmic technician, and examine how healthcare technology and training on an electronic medical record system is both helpful, and essential, for every practicing technician. This course will permit you to study how to quickly, and professionally, document your findings on a patient`s electronic medical record.
You will study how to efficiently enter in every of the information that you collect from the diagnostic tests that you run, as well as how chart every of your examination findings effectively, on the most cutting edge ophthalmic electronic health system on the market. The knowledge gained from this course will permit you to own a finish understanding on how to operate a comprehensive ophthalmic electronic medical records system, a key component of every modern ophthalmic practice.
MCCCD Official Course Competencies
Access system and study the difference between logging in/out and switch user. (I) 2. Protest how to search for a patient (five methods). (II) 3. Protest the taking of a new and an existing patient`s medical history. (III) 4. Protest the documentation differences dealing with a new patient and a returning patient. (III) 5.
Protest how to record a finish vision examination including present correction, manifest refractions and current contact lens prescription, and how to print. (III-XI) 6. Review and update a patient and patient`s family ocular history. (IV) 7. Protest the functionality of the summary examination chart and how to document common complaints. (IV) 8. Protest how to enter multiple pressure readings. (IV) 9. Protest other tests with which the technician may be concerned including color plate, stereopsis and Randot stereo test. (V) Protest how to document dilation drops as well as other ophthalmic drops and consents for both adults and minors.
(V) Define how to record every aspects of a patient`s general health, including smoking status and implications for meaningful use, and understand the shortcuts that are provided. (VI) Protest how to enter patient medications and how to manage these. (VI) Protest how to filter medications and how the technician can investigate discontinued and stopped medications. (VII) Protest how to record a patient`s surgeries, paying special attention to the diverse date mechanism. (VIII) Protest how to enter a patient`s allergies and their categories.
(IX) Protest how to open a new chart note, its structure and how to check significant indicators. (X) Protest how to enter a chief complaint and its implications (using RVS). (XI) Protest how to shut the chart and inform the doctor that the patient has been dilated and is ready for examination. (XII)
MCCCD Official Course Outline
I. Access system and study the difference between logging in/out and switch user. A. Log into the system B. User name and password characteristics C. Identify the person logged in D. Log in/out vs.
switch user E. Log out II. Protest how to search for a patient (five methods) A. Search fields and search results B.
Search formats C. Common searches D. Other searches and conditions: 1. Social security number 2. Telephone number 3. Date of birth 4.
Patient identification (ID) III. Protest the taking of a new and existing patient`s medical history A. Selecting patient from search B. Closing out a patient C. Chart note creation notification D. Chart note basic structure E. Examine new patient`s chart note F. Creating a new chart for an existing patient G. Examining existing patient`s chart note IV. Review and update a patient and patient`s family ocular history A.
Ocular history of patient and family members B. Review summary (left side of screen) C. Multiple family members affected D. Additional (istrative) questions E. Saving information V. Define how to record every aspects of a patient`s general health and understand the shortcuts that are provided. A. Arrangement of screen B. Primary care provider C. Advance directive D. Sugars and cholesterol reading E. Documentation by exception F. Marking problems and indications G. Basic medical conditions H. Tests and annual screenings I. Systemic conditions J. Smoking status requirements for meaningful use K. Social history VI. Protest how to enter patient medications, and how to manage these A.
No medications options B. Ocular medications table C. Importance of site D. Systemic medications table E. Ordered by F. Scan/upload VII. Protest how to filter medications and how the technician can investigate discontinued and stopped medications A. Stop and discontinue medications B. Color coding C. Information indicators and RxNorm codes D. Adding and deleting medication rows E. Filter medications list VIII. Protest how to record a patient`s surgeries, paying special attention to the diverse date mechanism A.
No surgeries/procedures check box B. Ocular surgeries/procedures C. Systemic surgeries/procedures D. Entering surgery dates E. Noting physician F. Adding and deleting surgeries IX. Protest how to enter a patient`s allergies and their categories A. No known drug allergies (NKDA) B. Link to e-prescribe database C. Adding allergies D. Documenting allergic reactions E. Deleting or discontinuing allergies X. Protest how to open a new chart note, its structure and how to check significant indicators A. Open a new chart note B.
Allergies button C. DOS and visit type D. Comprehensive or doctor preferred template E. Chart note templates F. Workspace description G. Patient at a glance H. Chief complaint, ocular medical history and ocular medications XI. Protest how to enter a chief complaint and its implications (using RVS) A. Common sections of the RVS B. Specifying a minor complaint C. Specifying a chief complaint (with four modifying conditions) D. Input screens and links E. Add free text F.
Add further minor complaints (if needed) G. Maximum chief complaints XII. Communicate with physician A. Shut patient electronic medical record (EMR) chart B. Inform physician patient exam preparation completed
Clock Curriculum Committee Approval Date:
All information published is subject to change without notice. Every effort has been made to ensure the accuracy of information presented, but based on the dynamic nature of the curricular process, course and program information is subject to change in order to reflect the most current information available.
Pertinent Past History
A patient’s medical history is a valuable tool in identifying or diagnosing a medical condition.
For instance, if a patient has a endless cardiac history, you would tend to own a higher level of suspicion for a complaint of difficulty breathing when there are no other outward signs.
Last Oral Intake
Knowing the final time a patient ate or drank, and what it was can assist identify a patients condition. For instance with a diabetic patient who is behaving erratically and states they haven’t eaten in 8 hours, you might be prompted to check their blood sugar level.
When asking a patient about allergies it is significant to make the distinction between medical allergies and non-medical allergies. Some allergies that may not seem medical in nature are significant however, such as peanut allergies since numerous asthmainhalers contain peanut by-products.
Common abbreviations used when recording that a patient has no allergies include NKA (No Known Allergies) and NKDA (No Known DRUG Allergies).
Signs and Symptoms
Signs are conditions you can see, such as a hematoma (bruise) or laceration. Symptoms are what the patient feels and tells you about, as in «my head hurts».
A list of medications that a patient is on is significant information to own, since the medications can give you an thought of what medical conditions a patient may own but hasn’t told you about, as well as ensuring that doctors don’t prescribe another medicine that conflicts with a medication that a person is taking.
An example of this is the dangerous relationship between Sildenafil (Viagra) and Nitroglycerine that can cause a person’s blood pressure to bottom out.