Taking a Patient History This course has been
Taking a Patient History
This course has been awarded 2 Group A credit by JCAHPO
his·to·ry A narrative of events; a story.
What is a Patient History? A patient history should be a summary of information about the patient including but not limited to the patient’s age, status of health, and the reason that patient is being seen that day in the patient’s own words as well as clarification of any symptoms or complaints the patient may have.
Taking a Patient History You should develop a pattern in taking patient histories to ensure that you are getting the complete story, in an efficient and concise manner. To do this you must know what information is important for the doctor to have, and what questions to ask to get that information.
Taking a Patient History When taking a patient history you sometimes you have to play detective
Parts of the Patient History $General Information $Chief Complaint $Past Ocular History $Past Medical History $Social History $Family History $Medication $Allergies
General Information Most offices will have the patient complete general information forms at the time of check in.
General Information Should include: $ full name $ address $ phone number $ date of birth $ insurance information
General Information Some offices may choose to include health and or symptom questionnaires in the general information forms patients are given to complete.
Chief Complaint The main reason for the visit that day is the chief complaint, the single most important piece of the patient history.
Chief Complaint Patients often do not understand the importance of the information they hold – that makes it necessary for you to take on the role of detective!
The Chief Complaint Sometimes it seems even Sherlock Holmes himself couldn’t tell you why Sally Smith is in to see the doctor today – you have to look for clues and know what questions to ask
Looking for Clues Some clues are very obvious – a patient with red, watery, lightsensitive eyes probably isn’t in for a routine exam for glasses
Looking for Clues Other times the reason for the visit is not obvious at all - a patient that calls in to schedule an eye exam because his glasses need changing may be just that – OR you may find out later that patient actually has loss of VA due to something more serious such as a retinal problem, etc.
Still Need More Clues?
ASK QUESTIONS!
ASK Questions Ask the patient “Ms. Jones, what brings you in to see the doctor today? ” OR “Ms. Jones, I see that you are in for your yearly exam today, are you having any specific problems with your eyes? ”
The Chief Complaint OK – now you know Sally Smith is in today because her eyes are red and painful – is that enough? That’s a start but now you need to ask more questions…
Example – Patient with a Red Eye What are your symptoms? Ask specifics…do they itch, burn? Are they mattered in the AM? When did this first start? Are you using any drops in your eye(s)? Do you remember getting anything in your eye(s)? Have you sustained any injuries to your eye(s)?
Example – Patient with Headaches How long have you been having the headaches? Is there a pattern in the occurrence? (Always in the afternoon, wakes up with them, etc. ) What if anything relieves your headache? Tylenol, sleep, nothing? Many times people with headaches have already seen their primary physician, or neurologist, make notes of any tests or treatment and treating physician’s name.
Example – Problem with glasses Are you having problems at a distance, up close or both? Do you feel like it is one eye or both that is bothering you? Take the patient’s visual acuities distance and near to see if there is any problem with how the patient’s glasses fit – does the bifocal sit too high, is the patient holding his book too close? “At what distance do you want to be able to see? ” Many times you will discover the patient’s needs are not being met with the present glasses – you should find out about the patient’s needs to determine the best type of bifocal etc. “What type of work do you do? ”
Ask questions but be careful with your answers Many times the patient is anxious about their condition, and you may have an idea what the condition may be. The patient may even ask you what you think. Be very careful how you answer…while in some cases you can give possible causes for the patient’s complaint you should also speak in generalities and tell them the doctor will look at all the information you have gathered any pre-tests you may do, as well as the exam he/she will perform and then the doctor will be able to discuss the findings.
Example – comments to a patient about a possible diagnosis (A patient in with increased floaters) It is the protocol at your office to dilate patients with these symptoms and let them watch an educational video. “Mr. Johnson, Dr. Smith will need to check the back of your eye today to make sure your complaints are just innocent floaters – while you are dilating he wants you to watch these videos about a couple of conditions that can cause symptoms like you are describing”
Past Ocular History When taking a history on a new patient you need to get the information about eye diseases or conditions the patient may have been diagnosed with in the past as well as any previous eye surgeries
Past Ocular History $ Refractive Status- note if patient wears glasses or contact lenses – type (glasses only for reading or soft daily wear contacts) $ Injury – date and type $ Surgery – date and type $ Disease- date diagnosed, any treatment(s), name of doctor that treated $ Extraocular Motility problems- date of any surgeries
Past Medical History Hypertension – HBP – medications and length of time since onset should be noted Uncontrolled BP can cause retinal hemorrhages, long-standing HBP can cause hypertensive retinopathy
Past Medical History Diabetes – note date of onset, diet controlled– insulin or oral meds, blood sugar under good control? Diabetes can cause fluctuation in vision, cataracts, diabetic retinopathy
Past Medical History Heart / Circulatory Problems – note dates of any heart attacks, strokes, etc. Can affect vision, CRVO, CRAO etc Arthritis – note if osteo or degenerative and what medications are being taken Can affect eyes with dryness or inflammation – iritis, episcleritis
Past Medical History Other diseases that can affect the eyes and should be noted if present are: Sickle Cell Disease AIDS Thyroid Disease
Past Medical History Surgeries – type and date should be noted
Social History $Smoking, Alcohol use should be noted. $Any emotional or mental disorders should also be noted.
Family History Positive family history (and how related) of the following should be noted: $Diabetes $Glaucoma $Color Blindness $Ocular Disease $Extraocular Motility Problems
Medications It is important to have a list of the patient’s current medication and dosages. Many medications can have ocular side effects as well knowing the medicines the patient is taking can offer the doctor insight to possible systemic disease that could have ocular manifestations. If the patient does not have a list with them make note of what the patient is taking the medications for and have the patient call you back with the correct information later.
Allergies Any allergies should be noted on the patient’s chart, prior to any drops being instilled in the patient’s eyes. Many patients may not realize that the drops used in the office are medicine and they can have a reaction if they are allergic to any of the ingredients.
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