OPHTHALMIC AND MEDICAL HISTORY
When the physician requests, the ophthalmic assistant begins the comprehensive eye examination by taking a preliminary ophthalmic and medical history of the patient. This information is entered in the patient's record and is generally reviewed by the physician before beginning the examination.
The purpose of the history is to determine the specific complaint that brought the patient to the office and to obtain information on any present illness or past ocular history that may help the physician in evaluating and diagnosing the patient's condition. Details on nonocular aspects of the patient's medical history and that of the patient's family may also prove useful.
The ophthalmic assistant obtains the history by asking a specific series of questions and recording the information in the patient's file or chart. The type and amount of information to be gathered by the ophthalmic assistant may vary from one practice to another. Some offices have special forms for this purpose. Here shows a sample form that might be used in a general ophthalmology practice. Irrespective of office policy, the history interview usually includes questions in five principal areas:
1.Chief Complaint
2.Ocular History
3.Medical History
4.Family ocular and medical history
5.Allergies
Here summarizes these principal areas of the history and their related questions, which are described in detail below.
I.Chief Complaint
The chief complaint is the reason for the patient's visit to the doctor, except in those cases where the comprehensive eye examination is a periodic evaluation of an asymptomatic patient. For patients with a specific visual problem, define the chief complaint with the following questions:
1. What are your symptoms?
2. When did the problem start?
3. Does the problem seem to be getting worse?
Depending on the patient's answers, you may have to ask additional questions in the following six areas:
1. Status of vision:
Have both near and far vision been affected ? Has vision been affected in one eye or both?
2. Onset:
Did the problem start suddenly or gradually?
3. Presence:
Are the symptoms constant or occasional, frequent or infrequent?(Ask the patient to specify the frequency in hours, days, weeks, or months.)Does a specific activity trigger the symptoms or make them worse?
4. Progression:
Has the problem become better or worse over time?
5. Severity:
Do the symptoms interfere with your work or other activities?
6. Treatment:
Have you ever been treated for this complaint? (If yes, ask how, when, and by whom.)
II. Ocular History:
The ocular history describes any eye problems the patient has experienced before this office visit, usually in reverse chronological order, that is, from the present to the past. The following are typical questions used to obtain the information:
1. Do you wear, or have your ever worn, eyeglasses or contact lenses? (If yes, ask at what age glasses or contacts were first prescribed and how old the present prescription is.)
2. Have you ever had eye surgery? (If yes, ask why, when and by whom.)
3. Have you ever been treated for a serious eye condition? (Ask specifically about glaucoma, cataract, injury or any other eye condition associated with visual loss.)
4. Are you taking any prescription or over-the-counter eye medications, including eyedrops? (If yes, find out the purpose,dosage, and duration of use).
III.Medical History:
A history of the patient's general medical health can be useful to the ophthalmologist because some health conditions can affect the eye and may influence the physician's choice of treatment. Ask the following types of questions:
1. Are you currently being treated for any disease? (If the answer is yes, ask the name of the physician).
2. Have you ever required treatment for any serious diseases? (Even if the patient answers no, ask specifically about diabetes and hypertension. Encourage the patient to think carefully about the question in order not to overlook a possibly significant disease.)
3. Are you taking any prescription or over-the-counter medications for a health condition? (If yes, find out the purpose, dosage, and duration of use. Ask women specifically about contraceptive pills because some patients don't think of them as a medication.)
IV.Family Ocular and Medical History:
Many health problems are hereditary, including ocular problems. For this reason, a history of the patient's family ocular and general medical health can be extremely useful. Obviously, only information about family members closely related by blood is required. Ask the following question:
1. Does anyone in your family have any significant eye or other health problems now; did anyone in the past? (Again, encourage the patient to think carefully. Ask directly whether any family members have ever had glaucoma, cataract, crossed eyes, poor vision, or blindness. Also ask specifically about diabetes, heart disease, hypertension, cancer, and conditions that run in the family.)
V.Allergies:
Not only can allergies be a source of eye problems, but they also can affect the patient's ability to undergo certain diagnostic tests or use medications or other treatments safely. Ask the following question:
1. Do you have any allergies to medications, pollen, food, or anything else? (If the patient answers yes, ask for specifics).
History-Taking Guidelines
Obtaining a complete and accurate history is a valuable skill that is developed only with experience. The following are some general suggestions to help you develop this skill.
1. When you begin the history, introduce yourself to the patient with your full name and explain the purpose of the interview. Address the patient by surname and title, depending on office policy and patient preference (that is Mr,Miss, Mrs or Ms). A simple approach is the following: "Mrs _______, my name is ________ ______. I am Dr._______'s assistant. I will be asking you some questions and performing certain tests to help the doctor with your examination." Remember, you are there to serve the patient. Be courteous and caring, but don't lose sight of the primary objective: to take an accurate history.
2. Be sure to find out whether the patient has been referred to your office by another person, especially by another doctor. Record the name of the person or doctor as part of the history. Ask if the patient has been seen previously as a patient by the ophthalmologist in your office.
3. Ask the name and relationship of anyone accompanying the patient, and determine whether or not the patient wishes these individuals to be present during the taking of the history.
4. When documenting the chief complaint, use the patient's words, not your own. Avoid substituting technical terms that the patient has not used. Stick to the facts as they are presented to you.
5. Patients may ask questions about their medical problem during the history interview. Handle these questions in a friendly manner but do not provide specific answers. Always refer the patient to the ophthalmologist for a diagnosis or medical advice, even if you think you know the answer. If the patient volunteers information you believe could be compromising(for eg, drug abuse or sexual practices), write this information on a separate sheet of paper for review by the physician. If the doctor deems the information relevant to the patient's condition, it can be transferred to the permanent chart. Do not include nonmedical information in the history.
6. Keep details short and to the point. The interview should take 5 to 10 minutes. Don't rush the process. Do a careful, thorough job, and when you are finished, thank the patient.
When the physician requests, the ophthalmic assistant begins the comprehensive eye examination by taking a preliminary ophthalmic and medical history of the patient. This information is entered in the patient's record and is generally reviewed by the physician before beginning the examination.
The purpose of the history is to determine the specific complaint that brought the patient to the office and to obtain information on any present illness or past ocular history that may help the physician in evaluating and diagnosing the patient's condition. Details on nonocular aspects of the patient's medical history and that of the patient's family may also prove useful.
The ophthalmic assistant obtains the history by asking a specific series of questions and recording the information in the patient's file or chart. The type and amount of information to be gathered by the ophthalmic assistant may vary from one practice to another. Some offices have special forms for this purpose. Here shows a sample form that might be used in a general ophthalmology practice. Irrespective of office policy, the history interview usually includes questions in five principal areas:
1.Chief Complaint
2.Ocular History
3.Medical History
4.Family ocular and medical history
5.Allergies
Here summarizes these principal areas of the history and their related questions, which are described in detail below.
I.Chief Complaint
The chief complaint is the reason for the patient's visit to the doctor, except in those cases where the comprehensive eye examination is a periodic evaluation of an asymptomatic patient. For patients with a specific visual problem, define the chief complaint with the following questions:
1. What are your symptoms?
2. When did the problem start?
3. Does the problem seem to be getting worse?
Depending on the patient's answers, you may have to ask additional questions in the following six areas:
1. Status of vision:
Have both near and far vision been affected ? Has vision been affected in one eye or both?
2. Onset:
Did the problem start suddenly or gradually?
3. Presence:
Are the symptoms constant or occasional, frequent or infrequent?(Ask the patient to specify the frequency in hours, days, weeks, or months.)Does a specific activity trigger the symptoms or make them worse?
Table: Summary of the Five Primary Areas of History-Taking
4. Progression:
Has the problem become better or worse over time?
5. Severity:
Do the symptoms interfere with your work or other activities?
6. Treatment:
Have you ever been treated for this complaint? (If yes, ask how, when, and by whom.)
II. Ocular History:
The ocular history describes any eye problems the patient has experienced before this office visit, usually in reverse chronological order, that is, from the present to the past. The following are typical questions used to obtain the information:
1. Do you wear, or have your ever worn, eyeglasses or contact lenses? (If yes, ask at what age glasses or contacts were first prescribed and how old the present prescription is.)
2. Have you ever had eye surgery? (If yes, ask why, when and by whom.)
3. Have you ever been treated for a serious eye condition? (Ask specifically about glaucoma, cataract, injury or any other eye condition associated with visual loss.)
4. Are you taking any prescription or over-the-counter eye medications, including eyedrops? (If yes, find out the purpose,dosage, and duration of use).
III.Medical History:
A history of the patient's general medical health can be useful to the ophthalmologist because some health conditions can affect the eye and may influence the physician's choice of treatment. Ask the following types of questions:
1. Are you currently being treated for any disease? (If the answer is yes, ask the name of the physician).
2. Have you ever required treatment for any serious diseases? (Even if the patient answers no, ask specifically about diabetes and hypertension. Encourage the patient to think carefully about the question in order not to overlook a possibly significant disease.)
3. Are you taking any prescription or over-the-counter medications for a health condition? (If yes, find out the purpose, dosage, and duration of use. Ask women specifically about contraceptive pills because some patients don't think of them as a medication.)
IV.Family Ocular and Medical History:
Many health problems are hereditary, including ocular problems. For this reason, a history of the patient's family ocular and general medical health can be extremely useful. Obviously, only information about family members closely related by blood is required. Ask the following question:
1. Does anyone in your family have any significant eye or other health problems now; did anyone in the past? (Again, encourage the patient to think carefully. Ask directly whether any family members have ever had glaucoma, cataract, crossed eyes, poor vision, or blindness. Also ask specifically about diabetes, heart disease, hypertension, cancer, and conditions that run in the family.)
V.Allergies:
Not only can allergies be a source of eye problems, but they also can affect the patient's ability to undergo certain diagnostic tests or use medications or other treatments safely. Ask the following question:
1. Do you have any allergies to medications, pollen, food, or anything else? (If the patient answers yes, ask for specifics).
History-Taking Guidelines
Obtaining a complete and accurate history is a valuable skill that is developed only with experience. The following are some general suggestions to help you develop this skill.
1. When you begin the history, introduce yourself to the patient with your full name and explain the purpose of the interview. Address the patient by surname and title, depending on office policy and patient preference (that is Mr,Miss, Mrs or Ms). A simple approach is the following: "Mrs _______, my name is ________ ______. I am Dr._______'s assistant. I will be asking you some questions and performing certain tests to help the doctor with your examination." Remember, you are there to serve the patient. Be courteous and caring, but don't lose sight of the primary objective: to take an accurate history.
2. Be sure to find out whether the patient has been referred to your office by another person, especially by another doctor. Record the name of the person or doctor as part of the history. Ask if the patient has been seen previously as a patient by the ophthalmologist in your office.
3. Ask the name and relationship of anyone accompanying the patient, and determine whether or not the patient wishes these individuals to be present during the taking of the history.
4. When documenting the chief complaint, use the patient's words, not your own. Avoid substituting technical terms that the patient has not used. Stick to the facts as they are presented to you.
5. Patients may ask questions about their medical problem during the history interview. Handle these questions in a friendly manner but do not provide specific answers. Always refer the patient to the ophthalmologist for a diagnosis or medical advice, even if you think you know the answer. If the patient volunteers information you believe could be compromising(for eg, drug abuse or sexual practices), write this information on a separate sheet of paper for review by the physician. If the doctor deems the information relevant to the patient's condition, it can be transferred to the permanent chart. Do not include nonmedical information in the history.
6. Keep details short and to the point. The interview should take 5 to 10 minutes. Don't rush the process. Do a careful, thorough job, and when you are finished, thank the patient.
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