How to define patient history
The seven essential components of patient history
How to effectively gather a patient's information
How to communicate patient history to both doctors and patients
What's the goal of this course?
The goal of this course is to improve the skills of the ophthalmic technician, both new and experienced. For the new technician, it is important to have a strong base on which to build the foundation of learning. For the experienced technician, it can be valuable to review the basics which may have been neglected with time. This course presumes that thorough history taking does not slow down patient flow, but rather by giving the doctor everything they need prior to seeing the patient, it will streamline the patient’s visit, and prevent the practice from running behind.
What is patient history?
The definition of patient history
In brief, a ‘Patient History’ refers to any information, past or present, that the doctor may find relevant to a patient’s medical care. This will generally include the reason for the visit, medical conditions and current medications, allergies, a review of symptoms, social history, and family history.
A well-documented patient history can often provide key pieces of information that the doctor needs to best diagnose and treat their patients.
What role does the ophthalmic technician play?
In a modern ophthalmic practice, the patient will often spend more time interacting with the ophthalmic technician than the ophthalmologist. It is because of this that the information gathered by the ophthalmic tech is critical to timely and effective patient care. The ability to collect a patient history with speed and accuracy is an important part of a well-run practice.
The seven crucial elements of patient history
Listed below are the seven things to keep an eye out for when collecting a patient's history.
A chief complaint is a quick summary of why the patient is there. It should include only the most pertinent information about the patient’s reason for the visit. In many cases, the use of electronic medical records (EHR) will in part determine the level of compensation for a visit based on the elements of the chief complaint. Remembering the acronym ‘FOLDAR’ can help complete many of the requirements of EHR.
FOLDAR stands for:
- Frequency – how often does it happen?
- Onset – when did it start?
- Location – where is happening/ which eye?
- Duration – when it happens, how long does it last?
- Associations – what do you associate with it happening?
- Remedies – what do you do to improve the symptoms?
By asking these series of questions, when applicable, the technician offers the doctor a clear explanation of the patient’s chief complaint while quickly completing the requirements of EHR.
Electronic medical records are working to standardize office visits by incentivizing offices to stick to a formula when taking histories. Most of these formulas stem from current Medicare requirements. Currently these software programs are far from uniform, and different EHR software will incentivize different keywords or tests, but there is certain information that most doctors consider necessary when recording a chief complaint.
For example, for a diabetic eye exam, the chief complaint should include what type of diabetic they are, how many years the patient has been a diabetic, their most recent fasting blood sugar, their most recent A1c, and what medication or insulin they use to control their blood sugar. When written out, this may look something like this:
“Diabetic Eye Exam. DMIIx17 years (Dx 2006), FBS 110, A1c 7.0, Controlled by Metformin”
By standardizing the way an ophthalmic technician charts their chief complaint, the doctor will easily know where to find the information they’re looking for.
Another common reason for a follow-up visit will be for glaucoma. Glaucoma visits should include the type of glaucoma the patient has (when known), any glaucoma medications they are taking and how often, the last time that medication was taken, and any side effects they may be experiencing. A standardized visit for a glaucoma follow-up may look something like this:
“Four month follow-up for POAG, Pt states compliance with Latanoprost OU QHS (last taken 930pm). Pt reports increased dry eye associated with gtts”
Lastly, most doctors want a chief complaint to include some mention of the patient’s vision. A patient’s perception of how well they see can tell a doctor a lot about how the patient is doing overall. If a patient has less than perfect vision, but feels they are functioning well with no complaints, a doctor would probably not recommend cataract surgery. On the other hand, a patient with relatively good Snellen acuity who feels highly symptomatic may be a candidate. This is why including a subjective assessment of vision in the chief complaint is valuable.
How a technician gathers a patient’s medical conditions will differ from practice to practice. Some offices have patients fill out their own forms, in which case the technician would just transfer what the patient has responded into the electronic medical records, while other practices will have the technician ask the patient directly.
Patients will often be dismissive when asked about medical problems or changes in their medical history. Rather than posing the question as “changes in their history,” the technician should reassure them that they are confirming that the office’s records are accurate. Rather than asking the broad question, “has anything changed since we last saw you?” ask a more direct question like, “We last saw you May 24 of 2018. Since that time, have you had any surgeries or hospitalizations?” This adds the context of a date, and asking about specific events will garner better results.
Similar to medical history, the patient may try to expedite the technician’s line of questioning by stating that “nothing has changed.” Keep the conversation open by continuing the pretense of “checking that the office’s records are accurate for the patient.” The technician can say, “We currently have you taking five medications,” and then list those medications for the patient. The patient may feel certain medications are not relevant to the eyes, but a large number of medications unrelated to eyes, from antidepressants to prostate medications, cause ocular side effects which makes knowing that the patient is taking them important. Even nonprescription medications like vitamins, such as fish oil or flaxseed, can have ocular side effects.
The purpose of knowing a patient’s allergies is to avoid interaction. Along with knowing a patient’s allergies, it can be valuable to know if the patient has had any adverse reactions to medications that may not qualify as true ‘allergies.’ This will be covered in greater detail in a later module on history taking.
Review of Symptoms (ROS)
A review of symptoms is a list of questions that are asked specifically about symptoms the patient is currently experiencing, like chest pain or joint pain. It may seem very similar to ‘medical problems’ and in some ways it is, but the key difference is a review of symptoms highlights the patient’s perception of their health. The ophthalmic technician can use the review of symptoms to ask better questions relating to medical history or medications.
Just as medical conditions and medications affect the eyes, lifestyle plays a role in ocular health. For example, it is important to ask patients about their smoking status, as nicotine weakens the vascular structure, and the eyes are comprised of small blood vessels. Employment status and hobbies are also important, as different professions will have different visual needs. Even what a patient did for work before they retired can be valuable, as patients who worked outside their entire working life are more likely to develop pterygiums, cataracts at a younger age, and macular degeneration.
Many medical conditions are hereditary, so asking about family history is important. It is more helpful to ask direct questions rather than vague ones. Rather than “Do you have a history of eye disease in your family?” it will be more successful to ask, “Do your parents, or did your grandparents, have macular degeneration, glaucoma, or other eye conditions?”
How to take patient history
Getting all the info
Every office will have their own system for collecting patient history, some offices will use forms that the patients will fill out themselves and then hand in to have scanned or transferred into the electronic medical record, but increasingly it is becoming the technician’s job to record the patient’s medical conditions, medications, allergies, social, and family histories. This means its critical that the technician asks the correct questions to get the information the doctor will need to properly treat the patient.
Connecting with patients
Having a connection with the patient is the easiest way to gather accurate information quickly, but making that connection is not always easy. Mirroring the patient’s tone or body language will make them feel more comfortable. The technician should always introduce themselves and explain the role that they will be playing in the patient’s care. Asking the patient about what they do for work, what hobbies they have, or what they did prior to retirement can aid both in learning about social history and visual needs, but can also help disarm the patient and keep them at ease.
Questions to ask
Knowing the right questions to ask is another key to quick and accurate history taking. How a question is asked is often as important as what is being asked. Many patients self-omit parts of their history that they deem unrelated to the reason for their visit, or they require prompting to be reminded.
When asking about medical history, rather than asking an easily dismissed question such as, “Do you have any medical conditions?” ask direct questions like, “Do you have diabetes, high blood pressure, or high cholesterol?” The technician can then broaden the question to “Do you have any other medical conditions?” Giving the patient time to think will often help them explain their conditions in greater detail and lead to great success in history taking.
Most offices will request patients bring a list of medications with them to every visit, but invariably there will be patients who do not. In those cases, it’s important that the technician does their best to create as complete a list as possible by asking pointed questions like “Do you take any vitamins or supplements? Do you know what they're called?” Once their Medical History has been established, the patient can be asked directly if they can remember the names of any of the medications for each medical condition.
Rather than simply asking a patient if they’re allergic to anything, ask them “Are you allergic to any medication, or are there any medications that you avoid taking because they make you sick or uncomfortable?” Broadening the question may help the patient remember a specific incident where a medication made them ill.
When the form isn’t enough
Although many offices give the patient these forms to fill out themselves, there will always be a need for clarification and expansion by the ophthalmic technician. By knowing how to ask the proper direct questions, the technician can keep the patient’s medical history complete and accurate.
Effectively communicating with patients
Patient communication and education
What is your role?
It is the role of the ophthalmic technician to prepare the patient for the doctor, complete any ancillary testing that has been ordered, instruct the patient on their medication usage, schedule and assist in procedures, and maintain patient flow through the day. There are often other administrative tasks that may be required of the ophthalmic technician, but in short, the role of the ophthalmic technician is to aid the doctor.
Explaining medications and treatments
One of the many ways the ophthalmic technician assists the doctor is in educating the patient on basic instructions after the patient’s exam is complete. Any time a patient is given a new medication, it is important to review any possible side effects with the patient prior to them leaving the office. If the side effects are temporary, give the patient a timeline that they should expect to experience them. Educated patients are more compliant.
When performing an ancillary test, such as an OCT or a visual field, take a moment to instruct the patient as to why the test was ordered, the purpose of the test, and what the patient’s role will be. Even if a patient has completed a visual field once every six months for a decade, they should not be required to remember what they are supposed to do. The ophthalmic technician should explain the test to the patient every time they administer it as if the patient has never completed the test before to avoid confusion.
Never ask a patient to sign a consent for a procedure without giving them time to read it first. If the patient is going to take too long, or will struggle with reading it on their own, the consent needs to be read to them.
The ophthalmic technician should ask the patient at least twice if they have any questions, and refer those questions to the doctor if necessary. Discussing the patient’s questions with them in a rhetorical setting may seem redundant, but the purpose is to help the patient articulate their questions more concisely, so when they speak with the doctor they ask questions that best represent the concerns they actually have.
Preparing the patient to see the doctor means three key things:
- First, it means taking a thorough and accurate history.
- Second, it means to identify with the patient any questions the patient may have and answer them or defer to the doctor.
- Lastly, the ophthalmic technician must anticipate the needs of the doctor once they’re in the room.
If the patient is in the office to have a procedure, that means preparing the room for said procedure, and printing a consent form when applicable. If the patient in due for ancillary testing, it is the job of the technician to complete the testing prior to the doctor seeing the patient, so everything is available for review when the doctor walks through the door. Anticipating need can be one of the most difficult parts of being an ophthalmic technician, but it can also save the most time.
Preparing patients to see the doctor
Communicating patient history to your doctor
Although the ophthalmic technician spends a great deal of time crafting a concise and thorough patient history, the doctor, upon entering the exam room, may not fully read it. That is not to say it isn’t valuable; the patient history is still extremely valuable, as it will be referred back to in the future. However, because the doctor may not have time to read it over fully, the technician has to develop ways to highlight relevant information for the doctor so it is not overlooked.
What to flag
Every office develops its own way of informing the doctor of key information that may be overlooked in a standard exam. Sometimes a simple note on the front of a chart can alert the doctor to come speak to a technician before going into the exam room. Other times, with electronic medical records, having a pop up alert the doctor may be more useful. Knowing how to alert the doctor is one thing—knowing what to alert them of is another.
As stated before, the ophthalmic technician interacts with the patient first, and often for a longer period of time than the ophthalmologist. If a patient is nervous, or combative, the technician is going to perceive that, and should absolutely communicate that to the doctor so they can be prepared.
If a patient has recently been diagnosed as a diabetic, the technician may want to print out education on diabetic eye disease so the doctor sees it upon entering the room and can spend extra attention on discussing the importance of managing their diabetes.
If the patient has a question that would be best fielded by the doctor, instruct the patient to ask the doctor directly. Depending on the nature of the question, it may be helpful to tell the patient to ask the doctor at the beginning of the exam, or save the question for the end. The technician should let the patient know their question has been written down, but it will be more valuable to the doctor to hear the question directly from the patient.
Thinking on your feet
There will always be situations which fall outside the normal scope of history taking, and in those times, the ophthalmic technician should be prepared to be flexible. Flexibility may be as simple as taking in a patient who has an appointment later on the schedule because they have arrived early, and the technician knows their appointment will take extra time.
The ability to use clinical judgement or anticipate need is a skill that develops with experience. When venturing outside the normal routine, the technician should check in with the doctor afterwards to get feedback. This will both let the doctor know there was thought behind the actions taken, and will assist the technician in knowing if they should do the same thing in the future.
A well-trained ophthalmic technician plays an invaluable role in keeping a practice running smoothly. With the introduction of electronic medical records and meaningful use requirements, the responsibilities of an ophthalmic technician are greater than they have ever been, but with the proper skills, it is possible to exhibit compassion and empathy while still maintaining a fast-paced work environment.