Review of Symptoms is the portion of an exam that screens for active physical signs and body system conditions. This article will explore how to document this portion of an eye exam in the Vision(X) EHR.
Review of Symptoms Menu
Select the Review of Symptoms category to open the documentation fields. If this field was documented by a non-provider (technician) or will simply not be completed as part of this exam, select the check box for "To Review" or "Not Performed" as appropriate. All non-completed fields can also be marked "no" by using the "Mark all remaining as No" button (this option exists within each Review of Symptoms documentation sub-field)
Ocular
Use this field to document ocular manifestations. When marking "Yes" for any option, additional fields will appear allowing the user to write specific notes and/or indicate the item as a complaint as appropriate. Each field also includes a general notes option for that field. When finished with Ocular documentation, click a different field name from the list on the left hand-side of the screen, or simply scroll down to proceed to the next listed field:
Vision
Use this field to document manifestations in the patient's vision:
Constitutional
Use this field to document "whole body" manifestations such as fever, fatigue, etc:
ENT
Use this field to document manifestations linked to "ear, nose and throat" conditions:
Neurological
Use this field to document manifestations linked to brain and nerve condition/functions:
Psychiatric
Use this field to document manifestations related to a brief inventory of mental health symptoms and indicators:
Cardiovascular
Use this field to document manifestations related to cardiovascular and systemic vascular conditions:
Respiratory
Use this field to document manifestations related to respiratory conditions:
Gastrointestinal
Use this field to document manifestations related to gastrointestinal conditions:
Genitourinary
Use this field to document manifestations related to conditions of the urinary and reproductive systems:
Musculoskeletal
Use this field to document manifestations related to conditions of the musculoskeletal system (bones, muscles, joints, ligaments, tendons and cartilage):
Integumentary
Use this field to document manifestations related to conditions of the integumentary system (skin, hair, nails and glands):
Endocrine
Use this field to document manifestations related to conditions of the endocrine system (tissues, glands, and organs related to hormone production and distribution):
Hematologic/Lymphatic
Use this field to document manifestations related to conditions of the hematologic (blood) and lymphatic (lymph) systems:
Allergic/Immunologic
Use this field to document manifestations related to allergies and/or conditions of the immune system:
