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ExamWRITER 8.0 Enhancements - OfficeMate Software Solutions

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<strong>ExamWRITER</strong> <strong>8.0</strong><br />

<strong>Enhancements</strong><br />

In this document:<br />

• Diagnosis/ Procedure Coding, 4<br />

• Quick Code, 6<br />

• Reason for Visit, 7<br />

• Chief Complaint, 8<br />

• Ocular Compliant, 10<br />

• Patient History, 12<br />

• Medical History, 13<br />

• Ocular Family History, 14<br />

• Surgery, 14<br />

• Pachymetry, 15<br />

• Vision/Rx, 16<br />

• Spectacle Rx, 16<br />

• Contact Lens Rx, 17<br />

• K-Readings History, 20<br />

• Orders, 21<br />

• Medication Order, 22<br />

• Examination / Special Testing, 23<br />

• ExamDRAW, 25<br />

• Images - Drawings, 27<br />

• Patient Information Center, 28<br />

• Quick List, 30<br />

• Exam Finalization, 31<br />

• Preferences, 32<br />

• Business Names, 34<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 1


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

• Medications Maintenance, 35<br />

• Patient Systemic Medications, 35<br />

• Templates, 36<br />

• Auto Letter, 37<br />

• Function Keys, 37<br />

• ePrescribing, 37<br />

• Equipment Interfaces, 37<br />

• Other, 38<br />

<strong>OfficeMate</strong> <strong>Software</strong> <strong>Solutions</strong> announces the newest version of <strong>ExamWRITER</strong>! In<br />

addition to resolving several known issues in previous versions of <strong>ExamWRITER</strong>,<br />

this updated version improves upon <strong>ExamWRITER</strong>’s current robust attributes and<br />

offers useful new features and expanded functionality. For additional information on<br />

<strong>ExamWRITER</strong> features, training, and integration with <strong>OfficeMate</strong>, contact<br />

<strong>OfficeMate</strong> <strong>Software</strong> <strong>Solutions</strong> at www.officemate.net or 800.942.5353.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 2


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Notes<br />

• If you are upgrading to <strong>ExamWRITER</strong> <strong>8.0</strong>, the templates that you<br />

previously created will need to be reprocessed due to changes that<br />

were made to the Quick Code functionality. Also, the information<br />

already recorded in exams that you copy forward to <strong>ExamWRITER</strong><br />

<strong>8.0</strong> will need to be reprocessed. After you upgrade to <strong>ExamWRITER</strong><br />

<strong>8.0</strong> you must open the exams that you copy forward and the templates<br />

that you created using previous <strong>ExamWRITER</strong> versions and reselect<br />

and reprocess all of the information in those exams. For more<br />

information on creating templates and recording information in<br />

exams, see the <strong>ExamWRITER</strong> Getting Started Guide.<br />

• For the new auto code feature to work properly with unilateral<br />

procedure codes (92226, 92135, 76519, 92225, and 92235), you must<br />

ensure that separate unilateral procedure codes for each eye are set up<br />

in the Customization window (Procedure Codes tab) in <strong>OfficeMate</strong><br />

or <strong>ExamWRITER</strong> (for example, 92226 RT and 92226 LT) prior to<br />

coding exams. Then, you must open the services in the Products<br />

window and select the appropriate right or left eye modifier for the<br />

procedure code.<br />

• <strong>ExamWRITER</strong> <strong>8.0</strong> requires the following system specifications:<br />

− Windows ® Vista SP1 or higher, Windows ® XP Professional,<br />

Windows ® 2000 Professional for workstations<br />

− 1024 x 768 monitor and video adapter screen resolution<br />

For a complete list of system specifications, go to<br />

http://www.officemate.net/PDFs/System Specifications.pdf.<br />

• If you are upgrading from <strong>ExamWRITER</strong> 5.x to <strong>8.0</strong>, ensure that you<br />

have read the <strong>ExamWRITER</strong> 5.1, 6.4, and 7.1–7.4 Enhancement<br />

documents located at<br />

www.officemate.net/support_ex_resources.aspx. In order for you to<br />

understand and use all of the new features that were implemented in<br />

each <strong>ExamWRITER</strong> version, you must read each version’s<br />

enhancement list.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 3


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Diagnosis/ Procedure Coding<br />

Diagnosis/<br />

Procedure<br />

Coding<br />

The new Auto<br />

Code feature<br />

means that you no<br />

longer have to<br />

remember coding<br />

rules and you can<br />

focus more on<br />

patient care.<br />

The improved Diagnosis/Procedure Coding window contains the following new<br />

features:<br />

• Ability to select and add modifiers to procedure codes.<br />

• Ability to view only the PQRI procedure codes by selecting the PQRI radio<br />

button.<br />

• Ability to automatically populate procedure codes in the Selected Procedures<br />

table. Based on your exam selections, <strong>ExamWRITER</strong> will automatically<br />

populate the Selected Procedures table. If the procedure codes are cleared, click<br />

Auto Code to repopulate the Selected Procedures table.<br />

Notes<br />

• Only the first 20 procedure codes selected in a new exam and<br />

listed in the Patient Open Charges window will transfer to a<br />

patient’s fee slip. If you do not want to post these charges, select<br />

them and click Close out.<br />

• For the auto code feature to work properly with unilateral<br />

procedure codes (92226, 92135, 76519, 92225, and 92235), you<br />

must ensure that separate unilateral procedure codes for each<br />

eye are set up in the Customization window (Procedure Codes<br />

tab) in <strong>OfficeMate</strong> or <strong>ExamWRITER</strong> (for example, 92226 RT<br />

and 92226 LT) prior to coding exams. Then, you must open the<br />

services in the Products window and select the appropriate right<br />

or left eye modifier for the procedure code.<br />

• For the new auto code feature to work properly with surgical<br />

procedure codes (67850, 68200, 68810, 67515, and 65860), you<br />

must ensure that the procedure codes are set up in the<br />

Customization window (Procedure Codes tab) and Products<br />

window in <strong>OfficeMate</strong> or <strong>ExamWRITER</strong> prior to coding<br />

exams.<br />

• If you select a 992xx procedure code and click Save/Exit, the<br />

E & M Quick Code Check window automatically opens so that<br />

you can reference quick code information. For information on<br />

the E & M Quick Code Check window, go to Quick Code on<br />

page 6.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 4


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Diagnosis/ Procedure Coding<br />

• Ability to click the Quick Code button and open the E & M Quick Code Check<br />

window and reference quick code information. For information on the E & M<br />

Quick Code Check window, go to Quick Code on page 6.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 5


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Quick Code<br />

Quick Code<br />

The improved E&M Quick Code Check window contains the following new features:<br />

• Ability to accurately and automatically determine the level of medical code<br />

documentation (based on the Evaluation and Management Services Guide by the<br />

Centers for Medicare & Medicaid Services (CMS)) needed for billing purposes<br />

on new exams. The check box selections that you record in a patient’s exam<br />

record that relate to 99xxx procedure codes are tallied and recorded in the<br />

Documented Elements row on the E&M Quick Code Check window.<br />

Now that you are<br />

able to increment<br />

and decrement<br />

coding levels in<br />

real time, you will<br />

be able to<br />

accurately select<br />

procedure codes<br />

for your exams. • Ability to quickly visually note what elements you have documented, what<br />

elements you have not documented, what E&M code you have already selected<br />

in the Diagnosis/Procedure Coding window (if applicable), and what alternate<br />

E&M code you can bill based on the elements that you have already documented<br />

(if applicable). The following color-coding is used in the E&M Quick Code<br />

Check window:<br />

−<br />

−<br />

−<br />

Note<br />

Due to the extensive changes that were made to the Quick Code<br />

functionality, the E&M Quick Code Check window will not<br />

accurately determine the level of medical code documentation for<br />

exams copied forward from <strong>ExamWRITER</strong> 7.4 and below to<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> unless you open the exams that you copied<br />

forward and reselect and reprocess all of the information in those<br />

exams.<br />

Grey boxes denote elements that you have not documented or coding<br />

levels that you have not reached.<br />

Purple boxes denote coding levels that you have reached.<br />

Green rows denote the coding level that you have already selected in the<br />

Diagnosis/Procedure Coding window (if applicable).<br />

− A red E&M Code box denotes an alternate E&M code that you can bill<br />

based on elements that you have already documented (if applicable).<br />

The lowest level of code that you have selected (as denoted by purple boxes) is<br />

what you are able to bill a patient. To meet CMS guidelines, you cannot bill a<br />

level 5 E&M code unless all of the boxes in the level 5 row are purple. For<br />

example, if there is a purple HPI box in the level 2 row and purple ROS, PFSH,<br />

Phys Exam, Diag/Mgmt, and Risk boxes in the level 5 row, you must bill the<br />

level 2 E&M code unless you document additional HPI elements to create a<br />

purple HPI box in the level 5 row.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 6


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Reason for Visit<br />

To meet CMS guidelines, you must document two out of three areas (History,<br />

Exam, and/or Medical Decision) for established patients.<br />

To meet CMS guidelines, you must document all three areas (History, Exam, and<br />

Medical Decision) for new patients; new patients are patients who have not been<br />

seen in your practice in at least three years.<br />

• Ability to click on the HPI heading and open the History of Present Illness<br />

window and record additional history information.<br />

• Ability to click on the PFSH heading and open the Ocular Family History<br />

window and record additional history information.<br />

• Ability to click the Diag/Mgmt heading and open the<br />

Impressions/Assessment window and record additional exam impressions.<br />

• Ability to click Coding and open the Diagnosis/Procedure Coding window and<br />

record and modify coding information.<br />

Reason for<br />

Visit<br />

The redesigned Reason for Visit window contains the following new feature:<br />

Streamlined content more accurately documents patients’ reasons for visiting.<br />

The following new fields have been added to the Reason for Visit window:<br />

The redesigned<br />

Reason for Visit<br />

window allows you<br />

to instantly access<br />

previous exam<br />

information and<br />

helps you to more<br />

completely<br />

document a<br />

patient’s reason<br />

for visit.<br />

−<br />

−<br />

−<br />

Patient Insurance (imported from the Insurance tab on the Demographic<br />

window in <strong>OfficeMate</strong>)<br />

Last Eye Exam (elsewhere)<br />

Referred by<br />

To record a patient’s referring doctor in the exam record, select a primary<br />

care physician or other physician and then select the appropriate PCP,<br />

Other Physician, or None radio button.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 7


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Chief Complaint<br />

−<br />

−<br />

Notes (previously entitled Special needs)<br />

To record notes in the Notes text box, left-click in the Notes text box,<br />

left-click on appropriate selections that appear (press F12 to add notes to<br />

your selection items), and then right-click to save your selections in the<br />

Notes text box.<br />

Lab Orders<br />

The most recent spectacle, soft contact lens, and rigid contact lens lab<br />

orders are displayed.<br />

Chief<br />

Complaint<br />

Note<br />

Due to extensive improvements and changes made to the Chief<br />

Complaint window in <strong>ExamWRITER</strong> <strong>8.0</strong>, chief complaint information<br />

recorded in <strong>ExamWRITER</strong> 7.4.1 and below exams will not copy<br />

forward to new <strong>ExamWRITER</strong> <strong>8.0</strong> exams, even if you have selected to<br />

copy forward chief complaint information in the Preferences window.<br />

The redesigned Chief Complaint window contains the following new features:<br />

The redesigned<br />

Chief Complaint<br />

window is now<br />

completely<br />

customizeable.<br />

• Ability to select Chief Complaint as your default exam view. For more<br />

information on the new feature that allows you to set up a preference so that<br />

Chief Complaint is your default exam view, go to Preferences on page 32.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 8


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Chief Complaint<br />

• Ability to record custom complaints and timeline information. HPI information<br />

is no longer included on the Chief Complaint window; instead, there is a<br />

separate HPI category bar and window for documenting a patient’s history. For<br />

more information on documenting a patient’s HPI in <strong>ExamWRITER</strong> <strong>8.0</strong>, go to<br />

Ocular Compliant on page 10.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 9


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Ocular Compliant<br />

Ocular<br />

Compliant<br />

Now the least<br />

experienced<br />

technican can<br />

easily and<br />

effortlessly<br />

document clear<br />

and accurate HPI<br />

information. Every<br />

element is specific<br />

to the chief<br />

complaint and<br />

nothing is<br />

generalized.<br />

The new Ocular Complaint window improves the accuracy and quality of ocular<br />

complaint documentation and makes the technician’s job of documenting complaints<br />

worry-free with the new HPI Wizard.<br />

To document an exam using this new window, select the new Use HPI wizard<br />

general preference. You can also select a preference to document HPI information on<br />

an exam record in a vertical, multiline format or in a horizontal, narrative format. For<br />

more information on this new preference, go to Preferences on page 32.<br />

To document a patient’s common ocular complaints, click the Chief Complaint tab,<br />

click the History Present Illness (HPI) category bar, select the Common<br />

Ocular Complaints check box, and click Process.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 10


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Ocular Compliant<br />

Search for and select a complaint in the box on the left side of the window (press the<br />

F12 key to add a complaint to the box) and then select an eye from the Eye<br />

drop-down menu. In the Keyword and Long Description text boxes, left-click to<br />

select the appropriate items from the drop-down menu list and then right-click to save<br />

your selections. To modify or add keywords and long descriptions, left-click in a<br />

Keyword text box and press the F12 key. If you prefer to add custom text instead of<br />

using the HPI Wizard, click the Custom Text button. After you have finished<br />

documenting an ocular complaint, click Save Item to add the complaint to the<br />

Ocular Complaint table at the bottom of the window. After you have finished<br />

documenting all ocular complaints, click Process.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 11


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Patient History<br />

Patient<br />

History<br />

The improved Patient History window contains the following new feature:<br />

When selected on the Patient History window, disposition and orientation<br />

information is recorded under the Examination category bar, per Medicare<br />

requirements.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 12


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Medical History<br />

Medical<br />

History<br />

The redesigned Medical History window contains the following new feature:<br />

Ability to easily document a patient’s Medical History, Ocular History,<br />

Systemic Surgery, and Ocular Surgery history from within one window by<br />

clicking the appropriate radio buttons in the top right corner of the window and<br />

opening appropriate history selections.<br />

You no longer<br />

have to fully<br />

complete one<br />

history subject<br />

before<br />

documenting<br />

another history<br />

subject. You can<br />

now fluidly<br />

document a<br />

patient’s history<br />

and follow a<br />

patient’s<br />

conversation in<br />

<strong>ExamWRITER</strong>.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 13


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Ocular Family History<br />

Ocular Family<br />

History<br />

The redesigned Ocular Family History window contains the following new feature:<br />

Ability to easily document a patient’s Ocular and Systemic family history from<br />

within one window by clicking the appropriate radio buttons in the top right<br />

corner of the window and opening appropriate family history selections.<br />

You no longer<br />

have to fully<br />

complete one<br />

history subject<br />

before<br />

documenting<br />

another history<br />

subject. You can<br />

now fluidly<br />

document a<br />

patient’s history<br />

and follow a<br />

patient’s<br />

conversation in<br />

<strong>ExamWRITER</strong>.<br />

Surgery<br />

The Surgery<br />

window is now<br />

exclusively<br />

devoted to<br />

operative reports.<br />

The new Surgery window displays the following new feature:<br />

Ability to document operative reports.<br />

To document operative reports, click the Surgery - Plan - Mgmt tab, click the<br />

Surgery category bar, select the operative reports that you want to document,<br />

and click Process.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 14


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Pachymetry<br />

Pachymetry<br />

Because<br />

pachymetry has its<br />

own CPT code<br />

(76514),<br />

observations must<br />

be recorded as<br />

interpretations<br />

and reports. You<br />

are now able to<br />

document these<br />

interpretations<br />

and reports from<br />

within the Special<br />

Testing category<br />

bar.<br />

The pachymetry impressions have been moved from the Pachymetry recording<br />

window to a new Pachymetry window under the Special Testing category bar.<br />

To record pachymetry impressions, click the Exam - Special Tests tab, click the<br />

Special Testing category bar, select Pachymetry, select appropriate check boxes,<br />

and click Process.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 15


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Vision/Rx<br />

Vision/Rx<br />

The improved Vision/Rx tab contains the following new features:<br />

• Ability to click on the blue Rx Notes flags and open the Rx window and view<br />

the contact lens trial and final Rx notes and spectacle final and alternate Rx<br />

notes.<br />

• New selection options in the Vision/Rx window.<br />

Spectacle Rx<br />

The improved Spectacle Rx window contains the following new features:<br />

• Ability to automatically populate procedure codes in the Diagnosis/Procedure<br />

Coding window based on your manifest prescription (and not your final<br />

prescription). For more information on the new feature that automatically codes<br />

exams, go to Diagnosis/ Procedure Coding on page 4.<br />

The manifest prescription is now displayed under the Impressions/Assessment<br />

category bar on the Surgery - Plan - Mgmt tab.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 16


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Contact Lens Rx<br />

• Ability to view the most recent lab order on all tabs in the Spectacle Rx window.<br />

• Ability to print the final spectacle Rx from the Final tab.<br />

To print the final Rx from the Final tab, click Print Rx.<br />

• Ability to easily record a 180 axis measurement.<br />

To record a 180 axis measurement, select the 180 radio button above the axis<br />

blue slider bar.<br />

• Ability to clear all visual acuities that have been previously recorded for an Rx.<br />

To clear all visual acuities previously recorded for an Rx, click Clear VAs.<br />

Contact Lens<br />

Rx<br />

The improved Contact Lens Rx window contains the following new features:<br />

• Ability to view the most recent lab order on all tabs in the Spectacle Rx window.<br />

• Ability to select a disinfecting regimen from the Disinfecting drop-down<br />

menu on the Final tab, which will print on the final and trial Rx.<br />

Notes<br />

• The Disinfection information that is recorded on the Contacts<br />

(Care Regimen) window will print on the first final Rx.<br />

Selections from the Disinfecting drop-down menu on the<br />

Contact Lens Rx - Final window will print on the second and<br />

any subsequent final prescriptions.<br />

• Only the disinfecting information that is recorded for the most<br />

recently saved final Rx is displayed under the Plan category bar<br />

on the Surgery - Plan - Mgmt tab.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 17


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Contact Lens Rx<br />

• Ability to print the final contact lens Rx from the Final tab.<br />

To print the final Rx from the Final tab, click Print Rx.<br />

• Ability to clear all visual acuities that have been previously recorded for an Rx.<br />

To clear all visual acuities previously recorded for an Rx, click Clear VAs.<br />

• Ability to record multiple final contact lens prescriptions on the Final tab.<br />

Many doctors have<br />

desired the ability<br />

to record multiple<br />

final contact lens<br />

prescriptions. This<br />

option is now<br />

available!<br />

To record multiple final contact lens prescriptions, click New Rx after<br />

recording a prescription. Click the arrows under #/of to view other final<br />

contact lens prescriptions.<br />

• Ability to view the most recent final spectacle Rx from a prior exam (if one does<br />

not exist in the current exam) and copy it to the trial Rx on the Trial tab.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 18


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Contact Lens Rx<br />

• Ability to easily record a 180 axis measurement.<br />

To record a 180 axis measurement, select the 180 radio button above the axis<br />

blue slider bar.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 19


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

K-Readings History<br />

K-Readings<br />

History<br />

The new<br />

K-Readings<br />

History window<br />

allows you to<br />

precisely track<br />

irregular corneal<br />

conditions.<br />

The new K-Readings History window contains the following new feature:<br />

Ability to view a graphical historical display of a patient’s keratometry readings.<br />

To open the K-Readings History window and view a graphical historical display<br />

of a patient’s keratometry readings, click the yellow Hx button in the<br />

K-Readings box on the exam chart window. Select the Flat, Steep, or Both radio<br />

button to change the display of the graph. You can copy the graph to a clipboard<br />

or print the graph using the icons in the upper left corner of the window.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 20


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Orders<br />

Orders<br />

The redesigned<br />

Orders window is<br />

now completely<br />

customizeable. It<br />

also contains a<br />

complete<br />

database of every<br />

ophthalmic<br />

surgical procedure<br />

and lab test.<br />

The redesigned Orders window (previously entitled Follow-Up Orders) contains the<br />

new features:<br />

• Ability to record Examination, Surgery, Test, Consult, and Laboratory<br />

orders within the same window by selecting the appropriate radio button.<br />

• Ability to customize orders by pressing the F12 key and adding, editing, and<br />

deleting orders on the Code Maintenance window.<br />

• Ability to select an eye for an order from the Eye drop-down menu.<br />

• Ability to easily record an order for today by selecting the Today check box.<br />

• Ability to save orders without timelines or action information by selecting the<br />

Save WITHOUT Timeline and Action Date check box.<br />

• Ability to open the Orders window anytime during an exam by pressing the F3<br />

key.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 21


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Medication Order<br />

Medication<br />

Order<br />

You can save up to<br />

15 clicks per Rx by<br />

selecting default<br />

medication values<br />

on the Medications<br />

Maintenance<br />

window and<br />

selecting the<br />

medication on the<br />

Medication Order.<br />

The updated Medication Order window contains the following new features:<br />

• Ability to open the Medication Order window anytime during an exam by<br />

pressing the F6 key.<br />

• Ability to record a medication’s expiration date in the Expiration Date field.<br />

The expiration date automatically populates to one year from the date of the<br />

order for all refill medication orders.<br />

Note<br />

You can only record a medication’s expiration date in<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> exams and higher. You cannot record a<br />

medication’s expiration date when you refill a medication order<br />

that was recorded in an exam created with <strong>ExamWRITER</strong> 7.4.1 or<br />

below.<br />

• Ability to print prescriptions with or without a provider’s signature. For more<br />

information on the new feature that allows you to record a provider or staff<br />

member’s signature in <strong>ExamWRITER</strong>, go to Business Names on page 34.<br />

Note<br />

Some states require an original signature on medical prescriptions.<br />

Check with your state regulatory agency to find out if printing a<br />

signature on prescriptions is legal in your state.<br />

Printing your<br />

signature on<br />

prescriptions will<br />

save you time!<br />

To print a prescription with a signature, click the Surgery - Plan - Mgmt tab,<br />

click the Plan category bar, select the Medication Rx check box, click<br />

Process, record the prescription, and click Print Rx w/Sig.<br />

• Ability to view discontinue information, discontinue dates, and allergy<br />

information in the Medication Hx table.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 22


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Examination / Special Testing<br />

Examination /<br />

Special<br />

Testing<br />

Because<br />

compliance<br />

guidelines dictate<br />

that special testing<br />

documentation<br />

must be kept<br />

separate and<br />

distinct from other<br />

exam<br />

documentation,<br />

we have created<br />

the new Special<br />

Testing category<br />

bar.<br />

The new Exam - Special Tests tab contains the following new features:<br />

• Separation of the Examination and Special Testing category bars on the<br />

renamed Exam - Special Tests tab.<br />

• Ability to automatically populate procedure codes in the Diagnosis/Procedure<br />

Coding window based on your examination and special test selections. For more<br />

information on the new feature that automatically codes exams, go to<br />

Diagnosis/ Procedure Coding on page 4.<br />

• Ability to document ophthalmic tests.<br />

To document ophthalmic tests, click the Exam - Special Tests tab, click the<br />

Special Testing category bar, select appropriate ophthalmic tests, and click<br />

Process.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 23


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Examination / Special Testing<br />

• Ability to accurately document refractive surgery.<br />

To document refractive surgery, click the Exam - Special Tests tab, click the<br />

Examination category bar, select the Refractive Surgery check box, select<br />

appropriate check boxes, and click Process.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 24


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

ExamDRAW<br />

ExamDRAW<br />

The redesigned ExamDRAW window contains the following new features:<br />

• New Cataracts, Gonioscopy, and Optic Nerve Cupping ExamDRAW<br />

template options.<br />

• New interface that allows you to more easily and accurately create a wide variety<br />

of drawings.<br />

You can now easily<br />

navigate through<br />

multiple drawings<br />

in ExamDRAW.<br />

To use the new interface, click a tab at the top of the window to open a drawing<br />

template; choose appropriate options (inverted or default view), diseases, tools,<br />

sizes, opacity, and colors; and click on the eyes.<br />

Notes<br />

• After you have recorded a drawing using a template and saved<br />

it, the tab denoting that template turns green. If you have<br />

recorded a drawing using a template but have not saved it, the<br />

tab denoting that template turns pink.<br />

• To undo, redo, or clear changes that you have made to a<br />

drawing, click Edit from the main menu toolbar and select<br />

Clear Changes, Undo, or Redo.<br />

• To delete diseases or text that you have placed on the eyes,<br />

left-click on the disease or text and select Delete.<br />

• To add auto text to the drawing when you add a disease, click<br />

File and select Configure to open the draw text box. Ensure<br />

that the Disease state text check box is selected to insert auto<br />

text on the drawing. You can modify the font type, size, and<br />

style in the draw window also. The auto text is documented on<br />

the drawing and the Autotext tab.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 25


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

ExamDRAW<br />

You can now easily<br />

access multiple<br />

drawings from<br />

within ExamDRAW<br />

simply by clicking<br />

on the tabs at the<br />

top of the window.<br />

• Ability to view text automatically generated based on the diseases added to the<br />

drawing on the Autotext tab.<br />

Auto text is automatically added to the Autotext tab when you add a disease to<br />

a drawing. The retina location is documented in Disc Diameters and clock<br />

position on the Autotext tab for central retina and entire fundus drawings. If you<br />

do not want to use the auto text, deselect the check box next to the auto text on<br />

the Autotext tab. You can use the text tool (the T icon) to add your own text to<br />

the drawing.<br />

• Ability to add comments to drawings.<br />

The redesigned<br />

ExamDRAW<br />

program<br />

automatically adds<br />

documentation to<br />

exam drawings.<br />

You can now view<br />

historical patient<br />

drawings without<br />

opening previous<br />

exams.<br />

To add general comments to the drawing, click the Comments tab and type<br />

your comments.<br />

To add comments to the auto text that appears when you draw on the eye, click<br />

the Autotext tab, double-click in the Comments column next to the auto text,<br />

and type your comments.<br />

• Ability to view a historical record of a patient’s drawings by moving the white<br />

slider bar to the desired date on the timeline or pressing your keyboard’s left and<br />

right arrow keys.<br />

• Ability to copy drawings from a previous date forward to the current date to<br />

modify and record them on the current date.<br />

To copy drawings forward, open a drawing from a previous date and click Copy<br />

Forward.<br />

• Ability to delete drawings.<br />

To delete drawings, click Delete.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 26


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Images - Drawings<br />

Images -<br />

Drawings<br />

The new Images - Drawings tab contains a category bar that, when clicked, opens the<br />

eDocuments window and allows you to view, add, edit, and delete electronic<br />

documents attached to the exam record. All images and drawings from ExamDRAW<br />

and diagnostic equipment will be displayed under this tab.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 27


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Patient Information Center<br />

Patient<br />

Information<br />

Center<br />

The improved Patient Information Center window contains the following new<br />

features:<br />

• Ability to view patient’s diagnosis codes (or, problem list) and procedure codes<br />

from previous exams on the Exam Hx tab.<br />

It is now very easy<br />

for you to view a<br />

patient’s complete<br />

exam history and<br />

problem list from<br />

within the Patient<br />

Information<br />

Center.<br />

For insurance<br />

billing purposes, it<br />

is now easy for<br />

you to view when<br />

tests were<br />

completed on a<br />

patient.<br />

Notes<br />

• If you have diagnosis codes recorded in previous exams that are<br />

outdated and no longer appear on the Diagnosis Codes tab on<br />

the Customization window, they will not appear in the<br />

Diagnosis/Problem List on the Patient Information Center<br />

window.<br />

• To display PQRI procedure codes in the Procedures Performed<br />

table and keep track of PQRI reporting, select the Show PQRI<br />

check box.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 28


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Patient Information Center<br />

• Ability to add a discontinued date to a medication on the Med/Surgical Hx<br />

tab.<br />

To add a discontinued date to a medication, right-click on the medication in the<br />

Medication History table and select DISCONTINUE. Select a date from the<br />

Date Discontinued calendar and click Save. The discontinued date appears<br />

in the Date column in the Medication History window.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 29


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Quick List<br />

Quick List<br />

Now, with a simple<br />

glace at the<br />

Patient Quick List,<br />

you can view<br />

which provider in<br />

your practice is<br />

seeing which<br />

patients.<br />

The improved Patient Quick List window contains the following new features:<br />

• Ability to view when a patient’s exam has been closed or finalized in the Room<br />

column. When a patient’s exam has been closed or finalized, the Room column<br />

automatically displays the text “CLOSED.”<br />

• New Provider (Prov) and Service columns. The Prov column displays the<br />

provider’s initials and provider ID (which is also displayed in the ID # box next<br />

to the provider’s name on the Provider/Staff tab on the Business Names<br />

window).<br />

• Ability to view patients in the Quick List who are assigned to all providers or<br />

view patients in the Quick List who are assigned only to the provider logged into<br />

<strong>ExamWRITER</strong>.<br />

To view patients in the Quick List who are assigned only to the provider logged<br />

into <strong>ExamWRITER</strong>, deselect the All Providers check box. The All Providers<br />

check box is only active when a provider is logged into <strong>ExamWRITER</strong>. Staff<br />

members logged into <strong>ExamWRITER</strong> will see all providers listed in the Quick<br />

List.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 30


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Exam Finalization<br />

Exam<br />

Finalization<br />

The improved Exam Finalization window contains the following new features:<br />

• Ability to Print Alternate Spectacle Rx.<br />

• Ability to Print Trial Contact Rx.<br />

• Ability to Print Patient Report.<br />

Note<br />

You must click the Coding icon in <strong>ExamWRITER</strong>, verify or add<br />

diagnosis and procedure codes on the Diagnosis/Procedure Coding<br />

window, and click Save/Exit before <strong>ExamWRITER</strong> will allow you to<br />

finalize an exam. If you have automatically recorded procedure codes in<br />

the exam, but the “Coding is Incomplete, Click Continue to Code<br />

Exam.” message appears, then you have not saved the codes in the<br />

Diagnosis/Procedure Coding window and you must do so before<br />

finalizing the exam.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 31


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Preferences<br />

Preferences<br />

The improved System Preferences window contains the following new features:<br />

• New General preferences that include<br />

− Ability to select Chief Complaint as your default exam view.<br />

− Ability to select a preference to use the new “HPI Wizard” to more easily<br />

and accurately document HPI information. If you choose to use the new<br />

HPI Wizard, you can also select a preference to document HPI<br />

information on an exam record in a vertical, multiline format or in a<br />

horizontal, narrative format. For more information on the new HPI<br />

Wizard feature in the Ocular Complaint window, go to Ocular Compliant<br />

on page 10.<br />

− Ability to select Slate grey as an exam background color.<br />

−<br />

Note<br />

You can no longer select yellow as an exam background color.<br />

Ability to select exam finalization defaults that will automatically print<br />

alternate spectacle and trial contact lens prescriptions and patient letters.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 32


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Preferences<br />

• New Defaults preference allows you to choose whether or not you want<br />

<strong>ExamWRITER</strong> to automatically select the “Unless otherwise noted below:”<br />

check box on the Patient History, Review of Systems, External Exam, Slit-Lamp<br />

Exam, and Routine Ophthalmoscopy windows.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 33


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Business Names<br />

Business<br />

Names<br />

The improved Business Names window contains the following new feature:<br />

Ability to save default provider and staff members’ signatures on the<br />

Provider/Staff tab that will print on medical prescriptions. For information on<br />

the new feature that allows you to print signatures on medical prescriptions, go<br />

to Medication Order on page 22.<br />

To save a default signature that will print on medical prescriptions, click<br />

Browse, navigate to the signature, and click Open.<br />

Notes<br />

• <strong>OfficeMate</strong> <strong>Software</strong> <strong>Solutions</strong> recommends saving all<br />

signatures in the eDocuments folder.<br />

• All signatures must be saved using the JPEG graphic format.<br />

• Some states require an original signature on medical<br />

prescriptions. Check with your state regulatory agency to find<br />

out if printing a signature on prescriptions is legal in your state.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 34


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Medications Maintenance<br />

Medications<br />

Maintenance<br />

The improved Medications Maintenance window contains the following new feature:<br />

New default values including substitutions, refills, application, frequency, and<br />

duration.<br />

You can save up to<br />

15 clicks per Rx by<br />

selecting default<br />

medication values<br />

and selecting the<br />

medication on the<br />

Medication Order.<br />

Patient<br />

Systemic<br />

Medications<br />

The redesigned Patient Systemic Medications window contains the following new<br />

features:<br />

• Medications are now listed at the top of the window and selections that you have<br />

made are now listed at the bottom of the window.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 35


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Templates<br />

• Ability to add a discontinued date to a medication in the Patient SYSTEMIC<br />

Medications table.<br />

To add a discontinued date to a medication, click on the medication in the<br />

Patient SYSTEMIC Medications table and then click Discontinue. Select a<br />

date from the Discontinue Date calendar and click Save. The discontinued<br />

date appears in the Date column in the Medication History window.<br />

Tablet PC users<br />

will find that it is<br />

much easier to<br />

view medications<br />

on this window<br />

now that they are<br />

listed at the top of<br />

the window.<br />

Templates<br />

The improved Template Maintenance window contains the following new feature:<br />

The new<br />

templates are<br />

available in line<br />

item and narrative<br />

formats. Some<br />

templates also<br />

have CPT codes<br />

pre-recorded in<br />

them.<br />

<br />

Availability of forty-seven new exam templates.<br />

Note<br />

Existing users must run the Update Template utility to add the new<br />

exam templates to <strong>ExamWRITER</strong>. This utility is available on our<br />

Knowledge Base at www.officemate.net.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 36


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Auto Letter<br />

Auto Letter<br />

The updated auto letter contains the following new note at the bottom of the letter:<br />

Note: The information contained in this report is confidential. Unauthorized disclosure may result in<br />

civil/criminal action as provided by HIPAA (1996) regulations.<br />

Function Keys<br />

You can now<br />

document orders<br />

and medications<br />

and view a list of a<br />

patient’s reported<br />

diagnoses anytime<br />

during an exam.<br />

The following function keys are now available to use in <strong>ExamWRITER</strong>:<br />

• F3 – Use this function key anytime during an exam to open the Orders window<br />

and record a patient’s examination, surgery, test, consultation, and laboratory<br />

orders.<br />

• F4 – Use this function key anytime during an exam to open a compilation of a<br />

patient’s reported diagnoses.<br />

• F6 – Use this function key anytime during an exam to open the Medication<br />

Order window and record a patient’s prescription medication.<br />

ePrescribing<br />

The new <strong>ExamWRITER</strong> ePrescribing interface allows you to quickly and easily send<br />

medical prescriptions electronically to pharmacies nationwide. Prescriptions that are<br />

electronically sent to pharmacies through the interface are recorded in the patient’s<br />

exam record in <strong>ExamWRITER</strong>.<br />

Note<br />

In order to use the new features in the <strong>ExamWRITER</strong> ePrescribing<br />

interface, you must have already purchased and activated the interface.<br />

For information on purchasing this interface, contact Sales at<br />

1.800.269.3666 or sales@officemate.net.<br />

Equipment<br />

Interfaces<br />

The improved equipment interface contains the following new features:<br />

Note<br />

In order to use the equipment interface, you must have already<br />

purchased and activated the interface. For information on purchasing<br />

the equipment interface, contact Sales at 1.800.269.3666 or<br />

sales@officemate.net.<br />

• New interfaces available with <strong>ExamWRITER</strong> <strong>8.0</strong>.21, including<br />

− Woodlyn Medmont<br />

− Comsquared Systems<br />

− Marco capture software<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 37


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Other<br />

• Ability to specify the start and end characters of data source files on the Setup<br />

<strong>ExamWRITER</strong> Equipment Interfaces window. These characters identify<br />

specific files from which the interface is importing data.<br />

To specify the start and end characters of data source files, click Tools on the<br />

<strong>ExamWRITER</strong> main window, select Equipment Integration Setup, select a<br />

device from the Available Equipment Interfaces box, select File from the<br />

Data Source drop-down menu, type the data file’s beginning characters in the<br />

Data File Start Chars text box, select the data file’s ending characters<br />

(extension) from the Data File End Char drop-down menu, and click Save.<br />

Other<br />

You no longer<br />

have to scroll<br />

through previous<br />

exams to open a<br />

specific exam;<br />

now you can easily<br />

select and view a<br />

specific previous<br />

exam.<br />

Other enhancements include the following new features:<br />

• Ability to more easily open a previous exam from within a currently opened<br />

exam.<br />

To open a previous exam from within a currently opened exam, select a date and<br />

primary procedure code from the Exam History drop-down menu on the<br />

exam chart window.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 38


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Other<br />

• Ability to quickly notice if there are contact lens and spectacle lab orders from<br />

the <strong>ExamWRITER</strong> chart window.<br />

• Ability to quickly view the most recent final spectacle and contact lens<br />

information under the Patient Management category bar on the Full View tab.<br />

• Business name address (or store name address for <strong>OfficeMate</strong> Enterprise users)<br />

is printed on examination records.<br />

• Patients’ DOB (date of birth) is printed on medical prescriptions.<br />

• Renamed Surgery - Plan - Mgmt tab.<br />

• Ability to use a scrollbar on the Notes and Addendum windows.<br />

• Ability to add a “Recorded By” user on the Notes and Addendum windows.<br />

• Ability to add information to addendums that have already been recorded.<br />

Note<br />

You can no longer edit information in addendums that have<br />

already been recorded; you can only add new information to the<br />

addendums.<br />

• Ability to view a patient’s name suffix when conducting a chart search on the<br />

<strong>ExamWRITER</strong> Control Center window, printing medical prescriptions, and on<br />

the blue title bar in <strong>ExamWRITER</strong>.<br />

• Ability to view a patient’s nickname in parentheses on the blue title bar in<br />

<strong>ExamWRITER</strong>.<br />

• The white box in the upper right corner of exams displays addendum<br />

information only.<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 39


<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong><br />

Other<br />

• Updated diagnosis codes in the Customization window.<br />

Note<br />

If you are upgrading to <strong>ExamWRITER</strong> <strong>8.0</strong> and the program is<br />

unable to find an identical match for a CPT code in your<br />

Customization window that it needs to update, it adds the new<br />

CPT code and modifies the old CPT code by adding a “z” to the<br />

front of its name (for example, “z_Trachoma, Unspecified”).<br />

<strong>ExamWRITER</strong> <strong>8.0</strong> <strong>Enhancements</strong> 40

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