Exam — overview
An exam is one visit's clinical record: history, measurements, refraction, diagnosis, and everything else the doctor needs to fill in. Every exam has its own workspace with a row of tabs across the top — one tab per section.
Layout
- Left column — the Encounters card lists this patient's exams (today's exam highlighted). + New Exams starts a fresh one. Below that is the Files card for scans and paper documents.
- Middle — the currently selected tab's form. Data is auto-saved as you fill it in.
- Right column — persistent sidebar with Medications, Allergies, demographic quick-fields (Occupation / Gender / Race / Ethnicity), and a Persisting Patient Note that stays visible across every tab.
- Bottom-right — floating Patient Page button jumps back to the patient card.
Tabs (in the order they appear)
| Tab | What goes in it |
|---|---|
| History | Ocular / family / social / ROS / meds / allergies / PCP. See History & CC/HPI. |
| Cc hpi | Chief complaint + HPI narrative. See History & CC/HPI. |
| Preliminary | VA, entrance Rx, pupils, color vision, IOP-lite, autorefractor, keratometer. See Measurements. |
| Refraction | Retinoscopy → Manifest → Cyclo → Final glasses Rx. See Refraction. |
| Cl fitting | Contact lens trial → fitting → final Rx. See Contact lens fitting. |
| External sle | SLE (slit lamp), IOP/tonometry with chart, gonio, drawing. See Measurements. |
| Posterior | Fundus findings, cup, notes. See Measurements. |
| Assessment | Diagnoses (ICD-10) + PQRS. See Assessment, Superbill & Referral. |
| Referral | Send patient to another doctor with a referral letter. See Assessment, Superbill & Referral. |
| Super | Superbill — procedures and invoice items generated from this exam. See Assessment, Superbill & Referral. |
| Details | Exam header info + Sign & lock exam + Delete exam. |
The exact tabs shown depend on the exam type (a Comp. Exam has more tabs than a follow-up), but the ones listed above are the common set.
Header actions
- Print Exam — opens a preview and PDF export of the whole exam.
- Back to Patient — return to the patient's card without saving anything new (auto-save has already saved your changes).
Working an exam start-to-finish
- Open the exam from Doctor's Desk → Unassigned Exams or from the patient's card.
- Work through the tabs left-to-right — most exams don't need every tab.
- On the Details tab, click Sign & lock exam when you're done. A locked exam becomes read-only (visible to billing, non-editable). If you need to change a locked exam, unlock via the same tab.
Related
- Doctor's Desk — overview
- Print an exam (if you have a dedicated print doc)