History Taking/Triage/Documentation Flashcards
Greeting
Identifying/Introduce yourself
Explain your role in the exam
Identify person(s) accompanying the patient (HIPAA)
Chief Complaint
Purpose of visit recorded in the patient’s own words
History or present illness (HPI)
Supporting Information for the chief complaint'
Physician referral
Symptoms
Sudden or gradual
How long have the symptoms been present
Has patient had these symptoms before
Severity
Frequency
Course-better, worse, no change
Associated signs and symptoms
Previous treatment
Medication
Surgery
Glasses change
Treatment by any other providers
Review of systems:
Respiratory systems (lungs)
Cardiovascular systems (heart and blood vessels)
Endocrine system (hormonal)
Nervous System (neurological)
Digestive and excretory system (gastrointestinal and urological)Past ocular history
Eye glasses-refraction stable Contact lens wear Any previous eye surgery Any ocular trauma, or eye disease Infections
Ocular Medications
Eye drops, ointments, or oral medications for eye condition
Dosage
Strength
Last taken
Compliance (patient follows the advice of the doctor, and takes the prescribed drugs in the quantities prescribed)
Past medical History
Medical conditions-i.e., diabetes, hypertension, etc.
Length of illness
Duration of treatment
Hospitalizations
Trauma
Surgeries
Mental Status
Pediatrics
Full term/premature
Birth compliance
Developmental HistorySystematic medications
Prescribed medications
Dosage
Strength
Duration
Compliance
Over the counter medications/suppliments
Dosage
Strength
DurationSocial and Vocational History
Smoking
How much
Duration
Alcohol (ETOH)
How much-e.g. socially
Duration
Abuse
Recreation drugs
How much
Duration
Employment/profession
Hobbies
Weight loss/weight gain
Marital Status/childrenFamily History
Ocular history
Systemic
Allergies
True allergies to medication(s) are hives or difficulty breathing.
Any other reaction is considered sensitivity and not a tru allergic reaction.
Ocular and systems medications (type of reaction)
Dyes
Contact lenses/solutions
Tape/latex
Seasonal
Environmental
Food
Scribe
Recording either in written form or electronically “verbatim” what the physician states while examining the patient.
Necessary documentation
A statement and signature of the ophthalmic technician stating that he/she recorded exactly what was stated by the physician and the physician’s name.
Complete
Statement and signature by the physician verifying that he/she indeed stated what was recorded and that the ophthalmic technician did record it
Telephone triage
Gather information
Determine the urgency of patient’s complaint
Proper triage is critical
An error in judgement may cause:
Pain and suffering
Loss of vision
Potential legal problems
Gathering information
It is important to be calm and reassuring when speaking to patients with urgent concerns:
Speak to the caller as though you are speaking face to face
When patients have an urgent concerns, they want to speak with someone who is concerned, reassuring and knowledgeable.
Be calm, but gather the needed information quickly and concisely
Listen carefully and document accurately
A patient with high anxiety needs reassurance even if the situation is not truly emergency
What information is needed?
Begin the triage process by recording patient’s answer to these questions:
What is the chief complaint?
Common urgent complaints may be blurred vision or loss of vision, eye pain, redness, discharge, light sensitivity or an acute injury.
Which eye is involved?
How did it happen? (for injuries)
When did the symptoms start?
Was the onset sudden or gradual?
Are the symptoms constant or intermittent?
Are the symptoms getting better, worse, or about the same?
Did you go to emergency room or your primary care physician before contacting our office?
have you ever had anything like this happen in the past?
Triage
prioritization of patient care (or victims during a disaster) based on illness/injury, severity, prognosis, and resource availability.
Emergent problems
True ocular emergencies-see as soon as possible
Urgent problems
Need same-day appointment
Priority Problems
Appointment within days
Routine problems
Routine appointments
Emergent problems-tru ocular emergencies (ask patient to come to office immediately)
Sudden loss of vision-painful
Sudden loss of vision-painless
Sudden loss of vision, painless with flashes, floaters
Penetrating injury
Chemical burns
Acute proptosis (bulging or protruding eyeballs) with loss of vision
Blunt trauma with sudden loss of vision and proptosis
Sudden loss of vision with headache
Sudden onset of diplopia with headache
Sudden loss of vision-painful
Red eye with severe pain, rainbow-colored halos, a cloudy cornea
Possible acute angle-closure glaucoma
Immediately measures to lower IOP
Definitive treatment with laser or surgery
Sudden loss of vision-painless
Sudden painless loss of part or all of visual field
Suspect vascular occlusion-central retinal artery, branch artery or central retinal vein
Check with doctor for possible therapy prior to arrival in office
Sudden loss of vision, painless with flashes, floaters
Suspect retinal detachment
May see veil or curtain
Loss of field of vision
Penetrating Injury
Potentially sight-threatening
Surgery required to restore structural integrity
Protect globe prior to surgery
Associated facial or orbital injuries
Often poor prognosis
Risk of infection
Multiple procedures may be required
Chemical Burns
Treatment required prior to full history
Irrigate the eye
Suspect associated mechanical injury depending on mechanism of injury
Time is the important factor in outcome
Acute proptosis (bulging or protruding eyeballs) with loss of vision
Accompanied by fever and malaise
Need to rule out orbital cellulitis
Blunt trauma with sudden loss of vision and proptosis
Need to assess for retrobulbar hemorrhage
Needs urgent canthotomy/cantholysis to release orbital pressure
Sudden loss of vision with headache
Associated with malaise, fever, weight loss, loss of appetite
Need to rule out temporal arteritis
Erythrocytes sedimentation rate, C-reactive protein, and platelet levels need to be assessed
High dose os steroids may need to be started to prevent further vision loss or contralateral loss.
Sudden onset of diplopia with headache
Associated with ptosis and a ‘blown’ pupil
Need to assess for aneurysm compressing the oculomotor nerve
Urgent problems-same day appointment
New onset flashes and floaters Blunt Trauma to the eye Sudden onset of double vision Red eye (may be minor problem or serious; many red eyes warrant a same-day appointment) Protrusion of an eye Contact lens problems
New onset flashes and floaters
Suspect retinal detachment
Often benign vitreous detachment
Requires dilated exam
Blunt Trauma to the eye
Vision may be difficult to assess
Orbital floor fracture (blowout fracture) may cause double vision
Occult rupture of globe
Detached or torn retina
Intraocular hemorrhage-hyphema or vitreous hemorrhage
Sudden onset of double vision
Patients may describe double vision but actually have ghost image To determine true double vision, instruct patient to cover each eye; if diplopia resolves, the patient has true double vision, requiring immediate attention True diplopia (often serious) CVA, diabetes, thyroid disease, brain tumor, metastatic lesion, neurological problems, hypertension or trauma. Ghost image can be addressed with priority appointment Possible cataract, media opacity or uncorrected astigmatism.
Red eye (may be minor problem or serious; many red eyes warrant a same-day appointment)
Red eyes accompanied by discharge, tearing, itching or swelling; suspect microbial conjunctivitis; keratitis or keratoconjunctivitis, allergies or dry eyes.
Redness with associated sharp, stabbing pain and light sensitivity; suspect corneal involvement; ulcers are urgent
Pain, photophobia, decreased vision and red ring surrounding the cornea; suspect iritis, often associated systemic problems
Bright red spot on conjunctiva with no associated symptoms; suspect subconjunctival hemorrhage; benign, but patients often require reassurance.
Protrusion of an eye
One or both eyes
Painful or painless
Sometimes accompanied by double vision
Suspect thyroid disease, tumors or orbital pseudo tumor
Contact lens problems
New onset of pain, redness, discharge, photophobia (very sensitive to it), poor vision or change of vision
Priority problems-should be within days of their initial complaint
Slow disease Progression Gradual, painless decrease in vision Lid problems Lost or broken eyeglasses Ocular Migraines and headaches
Slow disease Progression
(Emergency” requests sometimes from patients with long-standing condition)
Symptoms may have worsened
Anxiety
Underlying problem requires attention
Delay of a day or two unlikely to affect the outcome
Gradual, painless decrease in vision
Suspect cataract or macular degeneration
Chronic open-angle glaucoma can be priority appointments unless new pain, redness, severe headaches or seeing rainbows around lights
Lid problems
lumps and bumps; often caused by styes, etc.
Associated blepharitis
rare malignant lesions
Lost or broken eyeglasses
Patients unable to function
May need only limited appointment
Ocular Migraines and headaches
Ocular migraines are not necessarily a true emergency
May be difficult to differentiate from retinal detachment
Headaches that are chronic can be routine or priority appointment
Routine-make a routine appointment
Chronic problems that are slowly progressive:
Mild irritation or other problems that may resolve on their own
Some simply require patient instruction or a routine exam
Patients with long-standing floaters without flashes or changes in vision
Abnormal blinking
Dryness
Gradual changes in near or distance vision
Long-standing droopy eyelid
Small, yellowish raised bump on the white of the eye (pinguecula)
Glare with night driving
When in doubt
Check with doctor for guidance
Err on side of safety
Schedule patient ASAP
Gradual loss of vision
Ametropia (increase or change in refractive error)
Media opacitiesL mucus, cornea, aqueous, lens, vitreous
Receptor defect; Retina, optic nerve, chiasm, occipital cortex
Sudden loss of vision lasting >1/2 hour
Optic neuritis Occlusion of central retinal A or V Vitreous hemorrhage-often diabetic retinopathy Retinal Detachment Hysteria
Sudden loss of vision lasting <1/2 hour
Amaurosis fugax: transient ischemic attack (elderly)
Ophthalmic migraine: Occurs in second and third decade (not limited to)
Halo
Glaucoma and other causes of corneal edema
Cataracts or conjunctival secretions (infrequently)
Post laser vision correction (LASIK or PRK)
Curtain
Retinal Detachment or hemorrhage
Amaurosis fugax
Ophthalmic migraine
Flashes of light
Retinal: Vitreous traction or trauma to retina
Occipital: Migraine headache
Nyctalopia (night blindness)
Retinitis pigments
Other degenerations of rods receptors
Vitamin A deficiency
Spots
Muscae volitantes
Scotoma corresponding to defective area of retina
corneal foreign body
Diplopia
Monocular, hysterical or due to light splitting from corneal (double vision) or lenticular opacity
Binocular: due to muscle imbalance oor paralysis; eliminated by occluding one eye
Asthenopia (eye fatigue)
Phoria; fatigue of extra ocular muscle during attempt to maintain fusion
Hyperopia or presbyopia: fatigue of accommodative muscle
Other refractive errors; prolonged blur causes discomfort
Ocular tenderness
Episcleritis, endophthalmitis
Markedly elevated intraocular pressure
Lid or orbital inflammation
Scleritis
Photophobia
Uveitis Albinotic and lightly pigmented eyes Keratitis Conjunctivitis (infrequently) Corneal abrasion
Gritty Foreign-body sensation
Conjunctivitis Ocular foreign body Corneal Abrasion Dry eye syndrome Trichiasis
Itching and burning
Conjunctivitis-especially allergic
Occurs with asthenia
