Awareness : OBC Tips

Ophthalmic Diagnostic Tests

What is meant by the phrase “with interpretation and report” found in the description of most ophthalmic diagnostic tests?

It means that the physician must look at the results of the test, make an interpretation, and place a notation in the patient’s medical record within a short time of the test results being available. At a minimum, interpretation of a diagnostic test includes: the date of the test; the reliability of the test; the test findings; a diagnosis (if possible); the impact on treatment and prognosis, if any; and the signature of the physician.

An interpretation can be written on a separate page in the medical record, as a discrete entry together with other evaluation and management services, or in the blank space on the printout of the test results (e.g., visual fields). If the notation is placed on an exam form, it is important that it be identified as the test interpretation and not part of the exam.