The i-Clarity Clinical Records module consists of 4 record types: Pre-Screening, Clinical Records, CL Records and Other.

Note that patient information in the Clinical Records module is more sensitive than that stored in other parts of the system. It is strongly recommended that you use Maintenance/Form Permissions to create a user group for registered staff. You can then assign your professional staff to that group and ensure that only they have access to the full clinical records forms (CL Clinical Records, Clinical Records and Other Exam).

 

Minus Cyl vs Plus Cyl

Throughout i-Clarity, the system defaults to either plus cyl or minus cyl according to the preference of the logged in user. This is set in the User tab of Maintenance. 

 

Pre-Screening

The Pre-Screening module is intended for practices where other members of staff, other than the Optometrist, start the examination process outside of the test room. It allows an Optical Assistant to gather initial information allowing the Optometrist more time to concentrate on the examination and refraction.

If you are using the pre-screening in your practice, you should complete the pre-screening form before the full eye examination, otherwise there is the possibility that data entered into the full record will be overwritten by information from the pre-screening.

To open the Pre-Screening, click on the 'Clinical' icon.

This will open the Clinical Menu.

Click on the 'Pre-Screening' button. This will open the Pre-Screening Form for the active patient.

The behaviour and use of each of the pre-screening fields is described below.

 

Spec History

This is where the user can enter details of any pairs of spectacles that the patient may have.

1. Enter the date purchased (this must be a date in the form d/m/yy, but of course the patient may not remember so a date like ‘1/1/2016’ will usually be sufficient); the condition, the type of spectacles and frame description, then click ‘Add’.
2. When the spectacles have been added to the grid, you can then double click on the prescription column and enter details of the prescription:

Note 1: These details can be automatically imported from a connected, compatible focimeter by clicking the ‘Import Instrument Data’ button.

Note 2: Even if you are not using the Pre-Screen module, staff can still use the same functionality to add details of spectacles even while an examination is in progress. This is accessed from the ‘Further Details’ tab of the main patient form, by clicking the ‘Spectacle History’ button.

 

 Objective

You can enter details of the objective Rx in the appropriate boxes in the Objective section of the form:

These values can also be entered automatically from a compatible, connected autorefractor, by clicking the ‘Import Instrument Data’ button.

If the spherical powers have different signs, then these fields are highlighted in pink, like this:

 

Pachymetry

Enter the R and L values in the fields provided.

These may also be imported automatically from a compatible instrument, e.g. a Topcon TRK-2P.

 

Pressures

There is no need to enter the date, as i-Clarity will default to the current date and time (although you can edit if you wish, e.g. when entering pressures that were recorded previously.)

You then select the instrument from the instrument drop-down.

This can be configured so the list only displays the instruments that are used in your practice (Maintenance/Misc 5 tab), and also can default to the instrument most commonly used in the current test room, defined in Computer tab of maintenance, the Tonometer column.

You can then type in the R and L average values and click ‘Add’. Alternatively, by clicking the ‘More Detail’ button you can add up to 3 values for each eye; only the average will be displayed but the constituent values will be retained.

 

Reasons For Visit/Pre-Screen Notes

This is a text field, that can be completely blank so that you can free type whatever you want into it.

Alternatively, you can used 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 – that is, they are usable by all members of the practice, or Individual – they are specific to the currently logged in user.

Templates can be selected by clicking the 'Down' arrow.

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, by selecting the user from the User tab in Maintenance, and pressing the ‘Set Up Default Clinical Templates’ button; 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 either free type into the Reasons for Visit field or, if you are using templates with tags, select from pre-defined lists of answers. This is shown in the following illustration:

You can move to each tag by pressing the Tab key on your keyboard (that will automatically move the insertion point, firstly to the next colon (: ) and then into the following tag. You can then list the pre-defined answers by right clicking one or more of the pre-defined answers, then pressing ‘OK’.

Once you have entered your answer(s) you can then edit them in the field or tab to the next tag (or simply move to it with your mouse).

(Template and tag maintenance are described in the Maintenance section at the end of this chapter).

 

Patient’s Occupation

This allows you to specify the patient’s occupation from the pre-defined list of occupations. This updates the main patient record and appears on the title bar of the Clinical Records forms.

 

K Readings

This allows you to enter the K readings – these are also fields that can be added automatically from a compatible and connected device, e.g. a Topcon TRK-2P.

 

Pre-Screening Form – Buttons

Once you have completed the Pre-Screen record then click ‘Save & Close’. This will save all the latest data and return you to the main patient form.

 

Clinical Records

The Clinical Record is accessed by pressing the 'Clinical' button on the Main Patient form.

Then selecting 'Clinical Records' from the menu.

The first time you access the form for each patient you are presented with a blank clinical record; once you have created a patient’s clinical record then the most recent is displayed.

A new clinical record looks like this:

It is designed to be both completed and then read from the top left to the bottom right, following the ‘natural’ flow of information and the narrative arc of a ‘typical’ examination. Each of the data sections are listed in more detail below.

Once you start entering data into the Clinical Records field, the data will be automatically saved every 5 minutes; so even if your system has an outage, e.g. a power cut, then the most you will lose is any data entered in the previous 5 minutes – of course, if the power cut occurs just after the automatic save has occurred then you won’t lose any data at all.

 

Protecting your records – the i-Clarity Audit File

On both a personal and practice level, your clinical records contain the most important and irreplaceable information that you hold on your computer system. As well as using them day to day for normal clinical and dispensing purposes, you need to be able to have access to them outside i-Clarity for several other reasons. Some of these are listed below:

• Provide patients with a copy of their records.
• Provide copies to ophthalmologists or other optometrists.
• Provide lawyers or the GOC copies in the event of a dispute or FTP hearing.
• i-Clarity not working or no longer being maintained or rented.

To cover all these eventualities i-Clarity automatically creates a human-readable pdf ‘Audit File’ of each patient’s clinical record whenever that is created or updated. More precisely, and to avoid the number of these audit files becoming unmanageably large, it creates 1 audit file per patient per day. This is updated every time the patient record is updated on the same day. If the patient record is updated at a later date, then a new audit file is created.

These files are stored in the ‘Audits’ subfolder of each patient’s Windows folder in the location specified in the Branch tab of Maintenance, the Px Folders field.

Each file is cumulative i.e. it contains all the clinical data, including data from previous visits, that was stored up to the point that the file was created.

Note: The point of these files is that they ARE human readable, so you should ensure that your computer network is sufficiently secure, and that you have appropriate protocols in place, to prevent these files being accessed by unauthorised persons.

 

Using Templates and Tags

Several fields in the clinical record can be populated with templates that in turn can either be specific to the current user or ‘generic’ and used by all users within the practice.

The two fields in the Clinical Record that can contain templates are Main Reasons For Visit/Initial Patient Notes field, and the Right Notes/Left Notes fields.

You can select the template you want to use in each of these fields by clicking on the down arrow that is visible when that field is not selected.

This will allow you to select from either the ‘Generic’ (practice wide) templates, or those that you have created for your own use – ‘My Templates’.

In addition, you can set default templates for these two fields. This is done in Maintenance. Select the user from the User tab in Maintenance and press the ‘Set Up Default Clinical Templates’ button and choose what templates you want as the default for each field that can accept a template. 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).

Templates can simply contain text, to identify data items that you need to enter, or can contain ‘tags’, identified with pairs of chevrons: <<>>. By right clicking on a tag, you can then access a list of predefined answers from which you can select one or more then replace the selected tag with them:

Even when you have used tags, you can still free-type additional information or edit the existing answer.

Note in the example above you can enter additional answers ‘on the fly’, by typing in the new answer you want then clicking ‘Add This Answer’. This will both insert the selected answer into the record and add it to your list of personal answers for the selected tag. This feature can be disabled if required, (Misc 5 tab in Maintenance, ‘Allow Adding Tags on the Fly’).

If you have selected answers from the Tag Answer form and clicked ‘OK’, then the above dialog disappears. If you want to bring it back, e.g. because you want to add further answers to those you have already selected,  the you can press CTRL + ALT + T – this will bring up the list of all possible tags, and once you have selected one in the left hand list box the list of possible answers will appear on the right, as shown in the example below:

Several fields e.g. General Health and Dispensing Notes do not use templates but still contain tags, so you can save typing in these fields by predefining your answers and just selecting the text you want.

(Maintaining templates and tags is described later at the end of this chapter).

Clinical Records Fields

Occupation

Any selection made in this box will update the occupation field on the further details tab of the main patient record once the clinical record has been confirmed.

Once the clinical record is confirmed, the occupation that was selected in the clinical record will be fixed to that clinical record so that subsequent changes to the occupation field in further details do not edit the information that was recorded on the clinical record.

When you create a new clinical record, the occupation selected on the further details tab will be automatically selected in the occupation field on the clinical record - but it is open for editing if needed.

 

Previous Rx

The patient's previous prescriptions are displayed here in descending order of date. These are the prescriptions that can be viewed from the Summary Rx form on the main patient record, accessed using this button:

Note that you can also enter Rxs in the summary form, and this is how we recommend you enter prescriptions bought in from other opticians.  When the full Clinical Record module is enabled, the default test type for a new Rx in the summary form is set to ‘Test Elsewhere’.

When starting to use the Clinical Records module, you may find it useful to have support staff key in the most recent Rx in the summary form prior to the examination, as the details can then be copied from this previous Rx to the new Objective and/or Subjective fields in the latest record.

 

Main Reasons for Visit/Initial Patient Notes

This is a text field that can be completed in one of 4 ways:

• If your practice is using the Pre-Screen form, then the details can - and should-be copied from the most resent Pre-Screen using this button, found on the bottom right of the form:

         

• You can simply free type the information.
• You can set a default template for this field. (See the above section 'Using Templates and Tags' for how to do this).
• You can select a different template from the list of Personal and Generic templates by clicking the down arrow:

         

Whichever method you choose, you can edit the contents at any stage.

 

Unaided and Presenting VA

This where you record what the patient can see without and with their current spectacles. There is also space to record which glasses the patient was wearing when they achieved those results. Note that the VAs entered here also appear in non-editable greyed out boxes against the Objective, Subjective and Final Rx fields.

Note that you can specify the default scale used by each user, (‘6/’ and ‘N’ in the above example). This is specified in Maintenance/Users.

 

General Health/Occular History/Family History/Medication

These 4 boxes all come pre-populated with tags so you can predefine possible answers, (see the section on Maintenance at the end of this chapter how to do this).

In the list of possible answers for the <> tag, we recommend predefining family members – e.g. Mother, Father, Grandfather – as well as possible conditions, e.g. Glaucoma, diabetes, low vision etc. That way you can select a family member and the condition(s) that were associated with them.

When you select the <> tag, the possible tag answers dialog is slightly different, as it allows you to enter a medical condition, and then just display those medicines that are appropriate for the selected condition, as shown in the following example:

Note 1: The contents of each of these boxes is always copied forward to the next clinical record, and a new tag added to the existing content. Here is an example where a new patient record has been created for a patient, who in her last visit reported that she suffered from Asthma, Eczema and Hayfever:

You can then add to these conditions or delete any that no longer apply.

Note 2:  All clinical record data is, by default, output to a PDF file. This means that you can always read a patient’s clinical data, even if i-Clarity is no longer installed.  It also means that you can send the entire clinical record to a 3^rd party if required, e.g. the GOC or an ophthalmologist. However, we cannot guarantee the security of these audit files, as they are stored in Windows folders, and so their security is a function of your network setup/infrastructure. If there is information in these boxes that is of a particularly sensitive nature, then this can be excluded from the audit files by clicking the Mark as Confidential flag below the Medication field:

 

Pachymetry

You can enter pachymetry readings here; alternatively, they can be imported from a Pre-Screen record, or imported from a connected and compatible instrument.

The Previous Pachymetry button will display previous pachymetry values.

 

Pressures

Pressures can be entered in one of three ways:

1. From the Pre-Screen form described above.
2. By importing from a connected compatible instrument.
3. By typing the values in, in the test room. This is described below:

There is no need to enter the Date field, as i-Clarity will default to the current date and time (although you can if you wish, e.g. if you want to enter pressures that were recorded previously.) 

You then select the instrument from the instrument drop-down. This should be configured so the list only displays the instruments that are used in your practice (Maintenance/Misc 5 tab), and also can default to the instrument most commonly used in the current test room, defined in Maintenance/Computer tab, the Tonometer column.

You can then type in 3 values for the R and L, or just enter the average figures in the ‘R Av’ and ‘L Av’ columns; and click 'Add'. 

Note the pressures records are not linked to a specific clinical episode, so you can enter pressures on different days without having to create an entire new clinical record.

 

Spec History

Entering spectacle details is described in detail in the Specs History section of the Pre-Screen form.

Note that when spectacles are dispensed using i-Clarity, they will automatically be added to this list once those spectacles have been collected by the patient – and a note to that effect is displayed when you next access the Clinical record.

Also, to avoid the list becoming unmanageably long, you can remove spectacles from the list that are no longer relevant when reviewing the patient history. Highlight the pair that you no longer wish to display and press the ‘Delete’ button.  This only removes the pair from this list – the details will still be stored in the Sales and Orders forms of the patient record.

 

Right Notes/Left 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 that you want to follow.

There are six buttons that are displayed when the Notes part of the Clinical Record form is NOT selected (i.e. you have not clicked in to one of the three boxes. These are each described below:

 

Objective Rx

You can enter information into the Objective part of the examination in 4 ways:

1. By typing the values in directly - if you use the Tab key, then the insertion point will move to each box in turn. Once you have entered a value, e.g. cyl of 0.25, then you can 'tweak' this value by clicking the + or - symbols above the relevant column.
2. By importing the data from a compatible connected instrument such as an autorefractor.
3. By copying the relevant values from a previous Rx, displayed in the top left of the form. Select the Rx that you wish to copy by double clicking the grey box to the left of the Rx and you will then be presented with the following dialog:

         

        You can then copy the relevant fields from the selected Rx to the relevant Refraction. Note that you can transpose the Rx at this point; if the          original Rx is in a different form from the default for the current user the Transpose option is automatically selected. Also, there is an option            to Export the relevant data to a file; this is so the information can be picked up by a compatible, connected instrument such as a phoropter.

        4. The same functionality is also available using the prescriptions stored in the Spec History form. Just double click on the Spectacles you              wish to use, and you will be presented with the same dialog as above. (This is a good reason to ensure spectacles have been neutralised              before you start refracting the patient).

There is room for recording BVD and PDs against the Objective, however the PD field is a memo field only, and is NOT copied to either the Summary Rx form or the Dispensing form. This is by design.

As in the Pre-Screen form, if the spherical powers have different signs, then the sphere fields are highlighted in pink, as shown here:

This highlighting occurs in all 3 Rx fields.

The down arrow button to the left of the Rx will copy the objective Rx to the subjective Rx, which is described below.

 

Subjective Rx

The subjective Rx can be populated in the same 4 ways that the objective can be, with the additional method that it can also be copied from the objective Rx on the same record.

There are several additional fields associated with the Subjective, these are:

• Distance and near prism.
• Add
• V/A and near V/A.
• Pinhole.

To enter prims, click in the relevant field and you will be presented with the following dialog:

Enter the appropriate values and select the direction from the two drop-downs and click ‘OK’ to save.

Once you have entered the details of a distance prism, this can be copied to the near prism field by clicking the 'Copy Prisms' button. They can then be edited if required by clicking into the field.

 

Final Rx

This can be populated in 3 ways:

1. By typing in the values directly.
2. By importing from a compatible and connected phoropter.
3. By copying from a subjective Rx, by clicking the downwards arrow button that is to the left of the subjective.

     

This Final Rx is the Rx that is displayed at the top left of the form. It is also used to populate the summary Rx form that is accessed from the main patient form and is therefore the Rx used as the basis for dispensing.

 

Early Recall Code

By clicking on the ERC (Early Recall Code) you can select the reason that you have seen this patient earlier than would normally be allowed.

If you are going to recall the patient for an examination earlier than recommended by the NHS (meaning you will need to apply an early recall code at the next examination) then you can tick the box ‘use next test’. At the next examination i-Clarity will prompt you to apply an ERC.

 

Clinical Notes/Exam Outcome

This is intended as a narrative summary of the examination, e.g. ‘New Rx issued, recommended specs updated, gave leaflet on smoking, referred to GP’… You can pre-define possible answers using the <> tag, free type your summary, or a mixture of both.

The information in this field is available as a merge field, so can be used to create a standard document, e.g. a patient prescription that includes the summary outcome. 

Be aware that this information is also displayed on the Summary Rx form, so you should not use this field to record information of a sensitive nature.

 

Recommendation

This allows you to record what you believe the outcome of the examination should be, e.g. you believe that the patient should be dispensed new glasses, but of course you cannot ensure that they were.

This information is particularly useful for reviewing clinic outcomes. In the Clinic Outcome report, only option ‘No Rx’ is excluded from the total of tests that might be considered ‘Dispensable.’

 

Referred/Response

This allows you to record whether you need to refer a patient or not – and whether a response was received. You can find the list of patients who have been referred in the report ‘Referral Responses’ from the main Report menu.

If you tick the 'Referred' flag, this also automatically creates an Action assigned to you, in the Patient Activity tab. This means that if you do not have the time to do the referral there and then, you will see that you have actions outstanding whenever you log in to i-Clarity. This is shown in the top right-hand corner of the main form.

Double click on this message and you will see the outstanding action list.

 

Type

This is where you select what type of examination you have conducted. The options are shown below. Note that you will have the opportunity to change these before you finally confirm the examination details, as described in the following section, ‘Confirming Examination Details’.

Corporate - This is intended for examinations undertaken for 3^rd parties, e.g. for a local authority or fire brigade. The refraction will be considered valid so will be available for dispensing; you will need to add an appropriate fee when you confirm details in the ‘Confirming Examination Details’ form (see below for further details).

NHS - This is for 'standard' NHS eye examinations and will add an examination fee of the type 'NHS Fee' to the patient's sale. This will be selected by default if an NHS reason has been defined for this patient on the main form.

NHS Dom - This is for a domiciliary NHS eye examination and will add an examination fee of the type 'NHS Dom' to the patient's sale.

Private - This is for standard Private eye examinations and will add an examination fee of the type 'PVT ST' to the patient's sale. This will be selected by default if no NHS reason has been defined for this patient on the main form.

Re-test - This is for when a patient has returned for a re-test. This will not modify their recall date, nor will it automatically add a fee to the patient's sale (though you will be able to add one manually if appropriate, e.g. if the patient has an additional OCT scan).

Exam Elsewhere - This would not usually be selected from this form, but it is the default exam type when a prescription is added to the Summary Rx form. No fee is added for this exam type.

Non-Sight Test - This is for non-sight test examinations, e.g. WEHEs or Scottish supplementary. The prescription, if any, will not be used in dispensing or used as merge fields in Px docs, no fee will be added automatically, and no recall scheme will be added. If you wish to assign this patient to an additional recall scheme, you can do so manually from the Patient Communication tab on the main patient form.

Non-ST valid Rx - This is for a non-sight test examination where the patient was refracted and so the prescription is valid and can be used for a subsequent dispense. The other behaviour is as described above.

 

Recall Scheme

This is where you assign this patient to an appropriate recall scheme. The type of scheme that you can choose from is defined in the Recall Schemes tab of Maintenance – this form only displays those schemes of Scheme Type ‘Eye Exam’.

If a patient is already assigned to a recall scheme before this examination, (i.e. they are an existing patient) then this will be the default scheme; you should make sure that this is still appropriate.

Also, note that your system may be configured so that the patient’s ‘Next Due Date’ is automatically reset when the patient arrives for their appointment, rather than at the end of the examination. We advise against this when the clinical records module is being used, because you may change the examination type during the course of the examination, e.g. to a ‘Non sight test’ type, and want to leave the original sight test recall as it was. This can be turned off in Maintenance, Branches tab, ‘Arrival resets recall’ option.

 

Next Due Date

This defaults to the date of the current exam plus the number of days specified in the Maintenance/Recall Scheme tab for the selected Recall Scheme. This then becomes the date that is displayed on the main patient form, highlighted in pink if the next examination is overdue.

Note that you can overwrite this date with a different date of your choosing. This means that you don’t have to have recall schemes for every possible interval, e.g. instead of having a 3 Month Recall Scheme, 6 Month Recall Scheme, 9 Month Recall scheme etc, you can have a single scheme, e.g. ‘Next Recall < 12 Months’ and amend the Next Due date as appropriate. This can save a significant amount of maintenance, however if you do this you must remember to set the Next Recall date correctly from the main patient form/Communication tab, so that the patient receives their first recall before the Next Due date – the two are NOT automatically linked.

 

Dispensing Notes

This is where you can record any dispensing/lifestyle factors that you have discussed with your patient. The contents of this field will appear on the Summary Rx form and be copied through to any new dispenses.  There is a default tag - <> - which enables you to pre-define possible answers.

 

Clinical Record - Buttons

 

Finalising the Examination

When you first exit a new Clinical Record, you are presented with the 'Confirm Clinical Record' screen, which looks like this:

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 the button ‘Close Without Confirming Details’. This form will continue to be displayed whenever you access the clinical record until you click either of the two confirm buttons.

Because the information that you need to ‘confirm’ is so important there is a column on the ‘Clinic Outcomes’ report – ‘Fin’(finalised) – which is set to ‘Y’ once each clinical record has been confirmed. We strongly recommend reviewing this report after each clinic to ensure that all records have been fully completed. This way you can check that each record from the day’s clinic has been updated.