By Jerry Godwin, MBA, CEO, Optometric Medical Solutions
January 14, 2015
The concept of the medical process in an optometric practice is conveyed to the patient in the pre-testing process. Here, staff must explain the testing being completed and the purpose and medical nature (if it applies). At this point, have a meaningful discussion of the patient’s needs and explain that optometrists provide medical eyecare services.
It is not recommended that the staff develop the chief complaint. This is a doctor responsibility. The staff should notate the patient’s comments, and the doctor will confirm this information and develop the chief complaint and document it in the medical record.
Checklist of Duties: Doctor/Tech
• Provide clear messaging to the patient from the optometric tech. This will standardize expectations and deliver a consistent message of the purpose of the various tests.
• Techs use time to educate and ask questions regarding eye conditions that may lead to the medical exam.
• Document any medical concerns, making notes and verbally informing the doctor.
• For medical patients, complete HPI, ROS, PFSH if needed for that exam date to have sufficient documentation to properly code the exam when using E&M codes.
• Tech compiles the History of Present Illness (HPI) and ensures that the Review of Systems (ROS) and Past Family and Social History (PFSH) are complete for doctor review. (Some third-parties require the HPI be done by the doctor, not the tech.)
• Doctor reviews the HPI-ROS-PFSH, reviews the reason for visit or chief complaint.
• Doctor determines the chief complaint after a conversation with the patient.
• To be categorized as a medical visit exam must contain:
o Chief compliant that is medically necessary
o Clinical findings (medical necessity)
o Medical diagnosis
o Treatment plan
o Doctor’s signature.
Jerry Godwin, MBA, is CEO of Optometric Medical Solutions, based in San Antonio, Texas. OMS is a leader in providing comprehensive management services and systems to optometric practices and a “change agent” in helping practices to embracethe medical model.To reach him: jgodwin@optmedsol.com
