How to Navigate and Scribe in EMR Systems

Important Reminders

• Windows password: Welcome123

How to Navigate and Scribe in the EMR

Step 1: To verify the doctor’s schedule, click the profile (person) icon and select the facility. For example, select the Brooklyn facility if Dr. Patel is assigned there.

Step 2: To locate a patient, enter their name in the search field. The displayed result should resemble this example:

Step 3: The first step is to copy and paste the patient’s MRN. This ensures you can note the appointment and refer back to it when needed.

Step 4: Select the boxes in CC (Chief Complaint) and Patient History, then carefully review the contents. The boxes will change to purple once reviewed; green indicates they have not been checked yet.

Important: If a referring physician appears in the patient’s CC, make sure to record their name in the RP (Referring Physician) section above.

Step 5: To input the findings, select the WNL (Within Normal Limits) option and choose OU (both eyes) from the list.

Step 6: Verify the patient’s IOP (Intraocular Pressure) and CDR (Cup-to-Disc Ratio) readings. The IOP value appears next to iCare – 19, followed by the time of measurement. Document the IOP in your session notes as follows: MRN: 19/11. Ensure that the IOP value is less than 21, which is considered normal.

Step 7: Grid IOP Dilation

Ensure that both eyes are dilated. If only one eye is dilated, document it under the Fundus section (e.g., OD is dilated).

You can verify dilation by checking the drops used—typically Phenylephrine and Tropicamide.

If only OD (right eye) is dilated, it indicates OS (left eye) was not examined. In that case, click Peri NE and input OS in the text box.

Tip: If the doctor has already begun the examination, hover your cursor over the grid to be ready to record the diagnosis and findings promptly.

Step 8: Patient at a Glance

Review the patient’s information to determine the date of their most recent visit with Dr. Sabah Shah.

Step 9: Previous Plans and Assessment

Navigate to the Assessment and Plan section and hover over the previous plan. Select the date corresponding to the patient’s last visit with Dr. Patel.

Tip: Ensure that the current assessments follow the same sequence and structure as the previous plans.

Step 10: Medications

When the doctor instructs that the patient requires a medication request, open the eRx tab and select the correct option. If the medication is already on file, click RENEW to continue the prescription.

• To request a new medication at the doctor’s instruction, click New Rx.

  

  To view all medications for the patient, navigate to the Ocular Medication section. Remember to enter any medications your patient is currently using.

  

Step 11: History of CPT Codes

Navigate to the History of CPT Codes section to examine the patient’s prior insurance billing. Use this information to select the appropriate CPT codes for super billing.

Step 12: Return to Office (RTO)

Ensure you confirm the patient’s Return to Office (RTO). This information should be documented prior to the patient arriving at the front desk.

Tip 1: For patients returning in 6 months or longer, mark Comprehensive/Refract as the reason for return.

Tip 2: If a future appointment is already scheduled, record it in the Follow-Up section and choose AS SCHEDULED.

Step 13: Consult Letters

Before sending consult letters, select the appropriate template for the doctor and indicate the patient’s doctor in the letter.

Step 14: Finalizing the Patient's Chart

Do not forget to complete and finalize the patient’s chart.

Charts must be finalized no later than 3 days after the shift. Ideally, finalize them by the next day.

For printing MR1 or MR2 under Other Operation:

1. Edit the additional details as required.
2. Insert the Date of Service (DOS) between GIVEN and None, following the example below.

Then click the printer icon to print.

To complete printing the prescription, select the printer icon located in the top-right corner of the page.