The chief complaint of an eye examination contributes significantly to the patient’s exam flow. From an insurance standpoint, it is also required for proper compensation and reimbursement. In this article, the key components of recording a patient’s chief complaint will be addressed. We’ll review how taking a thorough case history will ensure accuracy and efficiency within your clinic.
Importance of accurate chief complaint
The first step in the examination process is always determining why the patient is presenting in order to perform an in-depth and accurate examination. This reason can be either doctor or patient-driven. Perhaps the patient is presenting for a doctor-ordered eye pressure check after starting glaucoma medication, or maybe the patient scheduled the appointment themselves due to vision changes or a red, goopy eye infection. Whatever the reasoning, establishing a purpose and detailing it clearly and concisely in the chief complaint is an important first step in guiding what testing may be necessary.
In many optometric practices, the responsibility of recording the medical history documentation falls onto the optometric technicians. It is an important task that should not be overlooked. While different optometrists and EHR systems may have their own nuances when it comes to recording a patient’s medical history, there are some standard guidelines that every technician can follow to ensure they are documenting an in-depth and accurate chief complaint.
How to acquire and in-depth chief complaint
An accurate chief complaint should consist of a brief statement that details the primary reason the patient scheduled the examination. It should typically be written in the patient’s own words. For instance, if a patient states that they are seeing a “spider web” in their vision, “spider web” is the term that should be used in quotations rather than as a diagnostic interpretation.
It is also important to capture all components of the complaint. This could include details, such as which eye is being affected, how long the symptoms have been present, if the problem is intermittent or constant, and if there are any relieving factors. There are multiple acronyms available that optometric technicians can recall as a tool for documentation to ensure as many details are captured as possible.
One of these includes the phrase “OLD CART.”
The number of areas addressed in the OLDCART acronym as part of the chief complaint will also help distinguish whether the exam can be billed as a brief or as an extended visit. The exam is considered brief if one to three areas are documented; it is considered extended if four to eight areas are documented. Any negative responses when pertinent to the complaint can also be counted.
“Additionally, the content of the chief complaint will help determine if the exam should be billed first to vision insurance or medical insurance.”
Some patients can be less forthcoming than others when sharing their complaints. It can be helpful to be educated on common ophthalmic conditions and their symptoms to determine what follow-up questions may be asked to elicit more helpful details from the patient.
Helpful follow-up questions
One of the first steps every optometric technician should take during each patient’s examination process is reviewing the patient’s past medical history, when available. Often, a patient may be returning for a doctor-ordered follow-up, or they may have a chronic condition, such as dry eye, glaucoma, or diabetes. Being aware of these important details not only helps drive the chief complaint but also creates a more personalized experience for the patient.
Being aware of a patient’s past history will also be necessary for asking helpful follow-up questions to make the chief complaint more detailed and complete. For instance, if a patient has been previously treated for dry eye, knowing this can lead to helpful follow-up questions; for example, asking if their symptoms have improved or worsened and how they are currently being treated.
Likewise, a patient’s symptoms or medical history can help determine what additional testing may be needed. This will increase the efficiency of the examination process and prevent the doctor from having to spend unnecessary time asking additional questions about the case history.
Common questions a technician may ask all patients who enter their office may include:
- Have you been noticing any vision changes such as blurred vision?
- Do you ever experience dry, watery, or gritty-feeling eyes?
- Do you often experience headaches or eye strain?
- Any eye pain?
- Have you been seeing any flashes or floaters in your vision?
If a patient answers "yes" to any of these questions, follow up with additional investigation, such as:
- How long has this problem been going on? (Onset)
- How often are you experiencing this problem? (Characteristics/Duration)
- Is there anything that relieves the problem? (Relieving factors)
Developing the chief complaint can often feel like detective work. While these are only a few examples of helpful follow-up questions, there is also a non-verbal element to communication that can make a patient feel comfortable enough to share more details.
The art of listening and emotional intelligence
The time a patient spends with a technician is often a fast-paced array of preliminary testing and questions. While being quick and efficient is extremely important to prevent the clinic from getting behind, it is also crucial that patients leave feeling like they had a personalized experience in your office.
“Ask questions and give the patient time to answer them; a patient should not feel rushed, even if the clinic is running behind.”
Improving communication also includes a big nonverbal component that helps a patient feel comfortable opening up and sharing more details. Friendly body language can go a long way in building a rapport with a patient. It will not only make them feel comfortable but also well cared for.
It is also important for technicians to be trained and familiar with the nonverbal cues that patients may give. This could be obvious when patients squint one or both eyes during visual acuity testing (e.g., uncorrected refractive error) or more discrete, such as patients presenting with sunglasses while indoors (e.g., iritis, corneal abrasion, metallic foreign body).
Picking up on these subtle nonverbal cues is important when recording the patient’s chief complaint, during the case history portion of their exam.
Protocol for documenting chief complaint
When a patient presents for an eye examination, they may have multiple complaints. No matter how small, every concern a patient expresses should be addressed so they feel heard and well cared for. These complaints should be documented in order of highest to lowest medical risk.
Finally, there are some questions a technician can ask themselves to be sure the chief complaint is complete, including:
- Is the complaint detailed and specific enough?
- Is the documentation free of grammar and spelling errors, and are the abbreviations considered appropriate and professional?
- Are the details and complaints in the proper order?
Conclusion
Ensuring the chief complaint is properly documented during a case history is a crucial step to an efficient and accurate examination. When an optometric or ophthalmic technician can conquer the chief complaint, this provides both patient and doctor satisfaction while also optimizing patient flow. Don’t overlook this opportunity to make patients feel heard and understood while also establishing positive rapport and building your practice!
