Reports

Reasons for a Medical Report

• Referral
  • A report is issued for every referral
• Report to the general practitioner
  • If requested by the patient/general practitioner
• Report to the health insurer
  • If requested
  • In case of a cost coverage inquiry (KoGu)

Structure of a Medical Report

• Greeting and, if applicable, thanks for the referral (automatically populated)
• Patient's name, address, and telephone number (automatically populated)
• Diagnosis list
  • Ophthalmological diagnoses (automatically populated)
  • Systemic diagnoses (only if related to the ophthalmological diagnoses)
  • Distance visual acuity (automatically populated)
  • IOP (automatically populated)
  • Findings (automatically populated)
  • Assessment and plan -> adjust in Hexabit Luna (automatically populated)
  • Signature of the treating physician
  • Responsible senior/attending physician (signed off electronically, does not need to sign by hand)

Assessment and Plan

The assessment is written epicritically, i.e. the findings and pathologies from the examinations are summarized and a conclusion is drawn from them in the form of a diagnosis or working hypothesis. Different possible treatments are weighed against each other, with reasoning given for the one chosen.

How to Write a Report in Hexabit Luna

• Reports -> search/insert recipient -> "formal report" -> a Word file opens
• Check diagnoses and findings, adjust the assessment and plan
• Add the senior physician or attending physician (sign-off by a specialist is required)

When Must a Report Be Created?

• Create and draft the report on the day of examination -> assign the task in Hexabit Luna to the responsible specialist
• The responsible specialist corrects the report, signs it, and forwards it to the front office for dispatch
  • Specialist -> note/addendum in the medical record: report created, billed (non-formalized report TarMED code: 00.2285)
  • Front office: -> report sent via email/post

Who Is Responsible for Writing a Given Report?

Reports should be written and sent with as little delay as possible.

The physician responsible is the one who examined the patient at the time the report is requested. This prevents reports from being passed on to other physicians and causing delays. No report should take longer than one week. If the responsible physician is absent, the report must be handed over to the covering physician.

If the documentation in the medical record does not provide sufficient information for a report, this must be forwarded to the responsible specialist or chief physician.