The i-Clarity Clinical Records module consists of 4 record types: Pre-Screening, Clinical Record, CL Clinical Record and Non-Sight Test (Supplementary Exam).

Contact Lens Clinical Record

The Contact Lens Clinical Record form is intended to record the clinical notes of any exam related to a contact lens appointment.

There are several text fields throughout the form that can be completely blank so that you can free type whatever you want into it.

Alternatively, you can use pre-created templates that have appropriate questions and (optionally) 'tags' - defined by right and left chevrons like these: << >> - that allow you to select from predefined lists of answers.

Templates come in two forms, either Generic - usable by all members of the practice, or Individual - specific to the user currently logged in.

Templates can be selected by clicking the down arrow (highlighted below). This will give you the choice of selecting from the list of generic templates or your own personal ones. Note that each user can set a template to be the default that is used in this field. If you do this, then you only have to select a template if you want to use a different one from the default, (e.g. if you have a different template for a child rather than an adult). 

You can move through the prompts in a template by pressing the Tab key on your keyboard. This will automatically move the insertion point to the next colon (:).

Contact Lens Clinical Record Form Features

To open the Contact Lens Clinical Record form, click on the 'Exams' icon at the bottom of the patient screen.

This will open the Exams Summary Screen as shown below. This screen will show you all of the previous exams the patient has had.

Then click 'New CL Clinical' to open the Contact Lens Clinical Record Form.

The behaviour and use of each of the form fields on the Contact Lens Clinical Record Form is described below:

Patient Details - The patient's Name, ID Number, Date of Birth and Age are shown at the top of the form.

Previous Prescriptions - All previous prescriptions are shown in descending order in the Previous Presciptions / Exams section. These can be scrolled through either using a mouse or the up and down arrows on the keyboard. The buttons at the side can be used to only show Eye Exams, CL Exams, Dispenses or Focimetered Spectacles.

Over-refraction - Any over-refraction can be recorded here. PVA = Presenting Visual Acuity and PNVA = Presenting Near Visual Acuity.

Copying the previous CL rx - Find the CL rx you would like to copy in the Previous Prescriptions / Exams box and Click on the 3 dots next to it. This will bring up the options to Copy To The Primary CL Prescription, Copy to CL Prescription Incorporate Over-Refraction, Copy as a New Trial Lens, Copy as a New Trials Incorporate Over-Refraction, Copy to Clipboard and Transpose to either a Minus Cylinder, Plus Cylinder or As Originally Entered.

Visit Notes - The visit notes box is a text box that can be completed by either free typing or completing a predefined template (or a combination of both methods). Prompts you would include on this template might be:

• Reason for visit - recheck, symptoms etc.
• Comfort of current lenses.
• Wearing time of current lenses.

Right Exam Notes and Left Exam Notes - This is where you enter details of the examination itself. Although you can free type in the relevant boxes, it is highly recommended that you create templates that contain prompts and tags for the procedure you want to follow.

Subjective Rx - A space is provided to record a Subjective Rx if it is needed, e.g. patient visual acuity is reduced and no adjustment to the contact lens prescription makes any improvement.

Scheme Detail - This is located at the top right of the screen and can be used to record details of any automatic shipment or supplier scheme the patient may be on.

Dominant Eye - This is located at the top centre of the screen. The dominant eye can be recorded by selecting from the drop-down.

Solution - This is also located at the top centre of the screen. You can select the solution the patient uses from a list of solutions on your system.

CL Prescription - Firstly, select the brand of contact lenses from the drop-down list. Once a brand has been selected, the first set of validation will be available for selection from the first value drop-down list. Then select the validated option for each prescription value, moving from right to left. Once you have completed the right eye, you can either complete the left eye in the same way or you can click the 'Copy Right to Left' button. This will copy all the values from the right eye to the left eye and then you can make any necessary edits as required.

Parameters - Under the prescription is a field for the right and left eye parameters. Anything entered in this field will be attached to the Contact Lens prescription and will be shown on contact lens orders in other areas of the system. This field is useful for RGP lenses.

Wearing Modality - This is located at the top centre of the screen. You can click on the tag for wearing modality to show the list of linked tag answers. There is also the option to Cut, Copy and Delete.

Visit Type - Select a visit type option from the drop-down list. The options available are Aftercare, New CL Rx, Update CL Rx, Replacement, Trials Evaluation and Emergency.

Recall Scheme - Select from the drop-down list at the top of the form the recall that is applicable to the patient. Selecting a recall scheme automatically updates the Next Visit Due and Expiry Date fields on the prescription. However, there is a 'Link To Recall' tick box next to the Recall Scheme. If this is unticked, the recall date will not be updated once the exam is saved. This option may be useful for Contact Lens Trials.

The Next Due Date will be displayed on the patient screen along with a note of the recall scheme the patient is on. You can amend the Next Due Date by clicking on the calendar icon. This will amend the date on the CL form as well as on the patient screen, but it will NOT amend the send date of the recall communication. This must be done in the Communications tab on the patient screen.

The Expiry Date links to CL Orders. For one off orders, expired CL prescriptions will show a warning before ordering. Recurring orders will stop if the CL Prescription has expired.

Keratometry - This was previously only visible by clicking on Show Keratometry. However, in Enterprise, this is displayed at the bottom left of the CL Clinical Record.

Form Buttons

This button copies the contents of the Right notes field into the Left notes field. Take care when doing this as this action will overwrite the contents of the Left field notes so you should do this before amending the contents.

When you click this button, the following message will pop up.

These buttons allow you to change the size of the text. The size you choose will be retained when you save the record. Note that you can specify the default text size for each user, by selecting the User tab in Maintenance and entering the default font size in the Font Size column. (The default is 10).

This button allows you to select the appropriate template for this examination, or a different one from the default if a default is defined for the current user. Note that you should choose your template BEFORE you start entering data as selecting a new template will overwrite any data that you have already entered.

This button displays all the clinical record notes fields in the form of a report that you can scroll through, print or export. You can view this at the same time as you are viewing and editing the clinical record.

Although the audit file is created or updated automatically whenever you exit an updated clinical record form, you can use this button to force an update to occur.

Once you have completed a clinical record, there may still be unused tags that you have not used because they were not necessary on this occasion. This button removes unused tags so that the final record is clearer. 

Note that this will NOT remove tags that are listed as required for compliance purposes. Also, if you wish to reinstate a tag, then you can press Ctrl + Alt + T to display the full list of tags appropriate for the current field.

This button allows a user to 'sign-off' the clinical record that has been completed by someone else, e.g. a student or pre-reg.

The Logistics button allows you to click on CL Dispense, Receive From Supplier or Collected by Patient.

The Go button allows you to leave the CL Clinical Record open and switch to the exam summary or create a new CL Clinical Record; close the Clinical Record and go to Sales & Payments, Orders, Direct Debit & Recurring CL Management or CL Dispensing; or close the record and go back to the Exams Summary Screen.

The drawings button opens up a new screen to add drawings to the clinical record.

The screen that opens looks like this.

This button allows you to turn the spell check on or off.

The Imaging button allows you to access the i-Clarity Imaging Menu, which allows you to take, store and review imaging data from a variety of different systems including fundus cameras, slit lamps and OCTs.

The Show All CL Rxs button opens up a new screen where you can add and view all CL Rxs that the patient has. The screen that opens looks like this.

The Add Additional CL Rxs button expands part of the CL Clinical Record to add other CL Rxs.

The CL Clinical Record will then look like this.

The CL Trials button opens a new screen where you can view and create contact lens trials.

The new screen that opens looks like this.

On this screen, there is also a tool in the Out column that allows you to rate how the trial has gone. When you click on the smiley faces, the following screen will appear. 

The Save button allows you to save the current record then continue working on it.

The Close button allows you to quit the Clinical Record.

Finalising the Examination

When you have completed the clinical record and click on Close, the following pop up will appear.

If you have definitely finished filling out the CL Clinical Record, click Save Changes. This will then bring up the Confirm CL Clinical Record screen, which looks like this.

This screen allows you to double check the visit type and recall selected and then to apply fees to the patient's account. You can also update the patient status.

Warnings: Certain Fields, when not completed, will cause a warning note to appear on this confirmation form. Theses include recall and template compliance options.

Fees: To assign a fee to this record so that it appears on the patient account when you confirm the record, double click on the relevant fee listed in the box. If you have selected a fee incorrectly, double click it in the bottom box and it will be removed and reappear in the available fees list.

Note: You do NOT have to complete this when you first exit a record, e.g. you may wish to close a record then return to it to decide an appropriate recall interval, or whether or not to charge additional fees or refer the patient. If this is the case, then click 'Close Without Confirming Details'. This form will continue to be displayed whenever you access the clinical record until you click 'Confirm'.

Because the information you need to confirm is so important, there is a column in the Clinic Outcomes report - 'Fin' (Finalised) - which is set to 'Y' once the record has been confirmed. We strongly recommend reviewing this report after each clinic to ensure that each record has been fully completed for that day's clinic.

NEW ENTERPRISE FEATURES IN THE CL CLINICAL RECORD

There are a few new features in Enterprise that have enhanced the CL Clinical Record that have made navigating both the clinical record and the system much easier. These are - 

The Enterprise Menu at the top right of the screen.

You can use this to access the Diary, the Screen View Menu, WalkIn Sales, the Refresh Button, the Screen Lock button, as well as accessing other i-Clarity Modules shown below.

Patient Details, Communication, Documents and Utilities.

Clicking on the patient drop down on the top left of the screen brings up the menu shown below. This makes it easier to show and edit patient details, save, send and view documents and send communications to the patient.

Electronically Read The Text In English

Clicking the button below will read the text aloud in English. You can also right click the button to change it to a different language.

Translate to another language.

Clicking the Translate To Another Language button will bring up a list of languages that the text can be translated into. This is particularly useful for Welsh practices that have to use both Welsh and English.

Electronically Read The Text In English

Clicking the button below will read the text aloud in English. You can also right click the button to change it to a different language.