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#60767 02/20/2014 6:57 PM
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Where do people put their vision testing?

Now my MA puts it in the CC area where she puts most of her input.
Does anyone use the Miscellaneous Vital signs area?
In the Exam area?

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Greg

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Greg,

I dictate my vision results for the medicare wellness exam just below my physical exam so it looks a bit like this:

....end of full exam....

POLST form reviewed

Timed up and go test 8 seconds

Vision screening: right 20/20 left 20/25 both 20/20

Reviewed Medicare assessment wellness questionnaire

Other providers: Dr. Jones, Dr. Smith

Labs:........

And then the assessment and plan section comes next




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jimmie #60788 02/21/2014 3:45 PM
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Depends on which version you are using.
We have 6.6.2.
PE -> Note -> Vision (There is a specific box for each eye)

Before I think we used the "Plan" box. An odd place for it. But we wanted the PE free text reserved for doctor only use.


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Mario #60798 02/24/2014 5:56 PM
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Originally Posted by Mario
Depends on which version you are using.
We have 6.6.2.
PE -> Note -> Vision (There is a specific box for each eye)

Before I think we used the "Plan" box. An odd place for it. But we wanted the PE free text reserved for doctor only use.
Presently on 6.3.3, looking at newer versions and it looks like AC was also considering this issue

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Greg

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We started using the "check in/checkout" way and the nurse uses the check in vitals box to document vitals, meds, c.c. etc. However, the vision testing CANNOT be documented this way, except for opening the chart and selecting the "more" button in the vital area. I have looked at this many times to see if there is a solution besides having to open the chart and there does not appear to be one. Does anyone know another way to document the vision testing besides having to open the chart?.
If there is no other way, then the chart has to be opened by the nurse to document vision testing. Since this is rarely done for sick visits it would not be a big problem.


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