Transcript case history 101 - Heart of America Contact Lens Society

Ashley S. Reddell, O.D.
Heart of America Contact Lens Society
February 2013
 Born
& raised in Haysville, Kansas
 Graduated from KU --- Rock Chalk!

Worked for an optometrist
 Graduated
from Southern College of
Optometry in Memphis, TN

Worked for an optometrist
 Completed

residency in pediatrics
Visited offices all over the country
 Joined
2 doctor private practice in
Leavenworth, KS
 Husband joined the practice 1 year later
 Understand
how to efficiently illicit a chief
complaint and history of present illness
(HPI’s)
 Understand how to take an efficient patient
and family medical history
 Understand how the case history plays into
the new meaningful use criteria
 Be
accurate
 Be efficient
 Be friendly
 Fake it ‘til you make it
 Medical
vs. Visual Complaint
 “What brought you into see the eye doctor
today?”
 “What is the main reason for your visit
today?”
 Secondary complaint

“Any other concerns you would like me to tell
the doctor about your eyes?”
4
HPI’s per complaint are required to
withstand an insurance audit
F
– Frequency
 L – Location
 O – Onset
 R – Relief
 I – Intensity
 D – Duration
 A – Associated Symptoms
 Frequency



How often does this occur?
Is it constant?
Exp: cc: Headaches

Frequency – 2x/week
 Location


OD/OS/OU?
Exp: cc: Headaches

Frontal
 Onset


When did it begin? Or how long have you noticed
it?
Exp: cc: Headaches

2 months ago
 Relief


Anything make it better?
Exp: cc: Headaches

Taking a break from the computer
 Intensity


Scale of 1 to 10 (or mild, mod, sev?)
Exp: cc: Headaches

6/10
 Duration


How long do they last when you have them?
Exp: cc: Headaches

2 hours
 Associated


Any other symptoms occuring?
Exp: cc: Headaches

Eyestrain
 YOUR


Symptoms
TURN!
Example: Blurred Vision
Example: Red Eye
 Disease/Illness


Any health issues?
Are you being treated by your primary care
doctor for anything?
 Medications

What medications are you taking, including OTC
and any eyedrops?
 Allergies


(MU)
(MU)
Any allergies that you know of?
No known drug allergies? NKDA - ALWAYS
specifically ask about drug allergies
 Eye

Disease
Any history of eye disease?
 Surgeries

/ Trauma
Any history of ocular surgery or trauma?
 Medications

Any ocular medications?
 Immediate



Family
Parents
Siblings
Grandparents
 Disease/Illness


Anyone in your immediate family have any
diseases we need to know about?
HTN, Diabetes are the big ones
 Eye

Disease
Anyone in your immediate family have an eye
disease? Including:



Macular degeneration
Glaucoma
Cataracts
 “Do
you or anyone in your immediate family
have a history of eye disease?”
 YOU control the conversation. Smile and nod
but get the patient back on track.
 Have your script down and use the same
routine EVERY time.

This helps you know you haven’t missed anything
 Practice
 Let’s
practice together!
 Contact


Info.
Email is the best way to ask a question.
[email protected]