Transcript Taking a Patient History

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 and 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.