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The eye examination record (called a Patient Encounter) is the central document in your eye care system. It is where the doctor or optometrist records everything that happened during a patient visit: what the patient complained about, what was found on examination, the diagnosis, the optical prescription, any medications prescribed, and any investigations or procedures ordered. Everything else in the system - prescriptions, investigation orders, referrals, and billing - traces back to this examination record.

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Before You Start

  • The patient must be registered.
  • An appointment should exist for this visit.
  • You need the Healthcare Practitioner role (Ophthalmologist or Optometrist).
  • Pre-screening vital signs and visual acuity should already be recorded by the ophthalmic technician before you start.

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Starting an Examination

The quickest way is from the appointment:
  1. Open the patient’s Patient Appointment record
  2. Click Create Patient Encounter
Alternatively:
  1. Go to Healthcare workspace → Consultation card → Patient Encounter → New
Patient Encounter form showing patient name, practitioner, encounter date, symptoms tab, diagnosis tab, and drug prescription tab
The patient, practitioner, and date auto-fill.

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Recording the Chief Complaint

In the Symptoms section, add what the patient has come in for: Common eye care complaints to add:
  • Blurry vision (distance or near)
  • Eye pain or discomfort
  • Redness
  • Floaters or flashes of light
  • Dry eyes
  • Watery eyes / discharge
  • Headaches after reading
  • Sudden vision loss
  • Double vision
  • Halos around lights
Select from your configured Complaint master or type a new entry. Add as many as apply.

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Recording Examination Findings

Use the Review Details (free text) field to record clinical findings that do not fit into structured fields: For an eye examination, this typically includes:
Review Details field in the Patient Encounter showing eye examination findings with visual acuity, refraction, slit lamp, IOP, and fundus findings

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Recording the Diagnosis

In the Diagnosis section:
  1. Click in the Diagnosis field
  2. Type the diagnosis and select from the configured list
Common eye care diagnoses to configure:
  • Myopia (Shortsightedness)
  • Hypermetropia (Longsightedness)
  • Astigmatism
  • Presbyopia
  • Dry Eye Disease
  • Glaucoma (Open-Angle, Angle-Closure, Normal Tension)
  • Glaucoma Suspect
  • Cataract (Nuclear, Cortical, Posterior Subcapsular)
  • Age-Related Macular Degeneration (Dry AMD, Wet AMD)
  • Diabetic Retinopathy (NPDR - Mild, Moderate, Severe; PDR)
  • Retinal Detachment
  • Hypertensive Retinopathy
  • Blepharitis
  • Conjunctivitis (Allergic, Bacterial, Viral)
  • Keratoconus
  • Amblyopia
  • Strabismus
Multiple diagnoses can be added in the same examination.

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Recording the Optical Prescription

The drug prescription section is used to record the spectacle prescription as well as any eye drop medications.

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Spectacle Prescription

Add the spectacle prescription as a line in the Drug Prescription section:
  1. In the Drug Code field, enter the prescription as a structured medication entry
  2. In the Dosage/Notes field, record the full prescription values:
Alternatively, use the Review Details free text field (above) to record the refraction and prescription, and use the Drug Prescription section only for medications.
Drug Prescription section inside the Patient Encounter showing a spectacle prescription entry and eye drop entries

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Eye Drop and Medication Prescription

For prescribed eye drops and systemic medications: For glaucoma drops, note the eye (right, left, or both) in the dosage instructions.

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Ordering Investigations

In the Clinical Procedures section, order any investigations needed: Common eye care investigations to configure as Clinical Procedure Templates: Select the investigation template and it will appear in the patient’s investigation queue for the technician to complete.

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Ordering Lab Tests

For pre-operative patients or patients with systemic disease: In the Lab Tests section, add the required tests:
  • Blood Sugar (fasting and/or random) - for diabetic patients and pre-operative assessment
  • HbA1c - for diabetic retinopathy patients
  • Complete Blood Count (CBC) - pre-operative
  • Urine Routine - pre-operative
  • Conjunctival swab culture - for infective conjunctivitis or pre-operative infection screening
  • ECG - for older surgical patients

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Applying a Treatment Plan Template

For common eye conditions, you can set up treatment plan templates that pre-fill standard orders:
  1. Click Get Applicable Treatment Plans at the top of the form
  2. Select the template (e.g., “Glaucoma Management - New Diagnosis” or “Diabetic Retinopathy Monitoring Protocol”)
  3. All standard investigations and medications fill in automatically
  4. Review and adjust for this specific patient

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Submitting the Examination

When the examination is complete:
  1. Review all entries - complaints, findings, diagnosis, prescriptions, investigation orders
  2. Click Save (auto-creates investigation and lab test records if enabled)
  3. Click Submit to finalise
Once submitted, the appointment closes and the examination is locked. Use Amend if a correction is needed after submission.

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Field Guide: Patient Encounter (Eye Examination)

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Troubleshooting

Investigation records were not created when I submitted the examination Check that “Submit Orders on Save” is ticked in the encounter, and that it is enabled in Healthcare Settings. If not, create the Clinical Procedure records manually. I cannot edit a submitted examination Submitted records are locked. Use Amend to create a corrected version. The patient’s prescription is not on the portal Prescriptions appear in the portal only after the encounter is submitted. Check that the patient’s portal account is active.

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Best Practices

  • Always note the visual acuity in the Review Details field even if pre-screening recorded it - the doctor’s final VA measurement is the clinically significant one
  • For glaucoma patients, always record the IOP measurement method (Goldmann, NCT, iCare) alongside the value - different instruments give different readings
  • When ordering investigations, note in the clinical notes why each investigation was ordered - this helps the technician prioritise and helps future clinicians interpret the results in context
  • Never leave the Diagnosis field blank - an examination without a diagnosis cannot generate diagnosis trend data and may cause billing issues
  • For cataract patients, note the grade of cataract (nuclear sclerosis grade 1-4, cortical, PSC) and whether it is affecting the patient’s visual function - this is needed when deciding the right time for surgery