Documentation

And now let’s move on to how to document the visual fields test. And again, please determine with your doctor, how they would like the results of the test documented within the patient's EMR. You’ll likely want to provide a print out of any visual field deficits and scan a copy into the patient’s chart. It is important to identify what is normal and not normal, as you’ll want to alert the doctor of those findings. And it is their job to interpret the report for the patient. Also, as you become familiar with reports, understand that there is typically a black spot on the right that indicates a normal blind spot within the right eye and then a black spot on the left indicates a normal blind spot within the left eye.

When it goes to documenting, again this is just for general purposes, but typically the same concepts will apply for all EMR systems. So, it will have you identify how were the visual fields screening test performed. Was it done with an automated machine or was it done with confrontation. Indicate the results of the right eye and then the left eye. For confrontation fields, you’ll want to, if it was full, that is the patient was able to indicate the hand count in all four quadrants, you’ll do a full to finger count, which is FTFC. Or document if there are any limitations.

For an automated screening, you’ll want to notate if the patient had full results or if there was any limitations. It will also probably ask you to indicate what method was utilized during the automated visual fields screening. So, whether it was an FDT, what type of screening, or was it performed with a matrix. So, you can typically indicate that within the patient EMR. And that concludes on how to document for a visual fields findings.