Dr. Watson's Guide to History Taking
The "Dr. Watson" in the title is a reference to Sherlock Holmes' sidekick. It always took Sherlock Holmes' superior sleuthing skills to solve the case, but Watson was an able assistant, and he never tired of trying to keep up with Holmes. In the medical field, the best history takers are doctors because of their superior knowledge of the subject matter, but they rely on ophthalmic medical personnel to be as thorough as possible to lay the groundwork for a thorough and efficient exam. Your skill as a history taker will increase as your knowledge of ophthalmology in particular, and medicine in general, increases.
In the “good old days” we didn’t have to be concerned about the details and completeness of our history taking. Many patients came in for their “yearly exam” or were “sc” (without complaint). That sort of history taking won’t fly anymore. Many insurance companies won’t pay for a routine ophthalmic exam, and Medicare now uses three key components for determining the level of service and payment for an ocular exam. The components are: history taking, examination, and medical decision making. I can assure you that your ophthalmologist now considers good history taking to be a very important aspect of your job.
Chief Complaint (CC)
The glaucoma patient coming back for a pressure check truly may not have any complaints. Just record that the patient has glaucoma and is returning for a pressure check. This is reason enough for the exam.
The patient does not have to talk to you. It is the patient's right to only talk to the physician if desired. If the patient is too chatty, be interested in the conversation, but take opportunities to re-direct the interview back to the history.
A person in the exam room with the patient may have valuable information regarding the patient's history, especially if the patient is a child or a person with a mental disability. However, CC and HPI information directly from the patient must be separated from information obtained from another person. For example, information from a child's mother can be identified by writing "The mother states that ...".
You sometimes see the HPI elements listed in terms of the anagram "COLDER", as follows:
Although the "COLDER" list may be easier to remember, I think the other list does a better job of guiding you through the pertinent elements of the history.
When recording the history, it is not necessary or desirable (in the interest of time) to record everything the patient says. You will need to be a good editor, recording only what is pertinent to good coding and good patient care. Use standard abbreviations to save time and space. A record of Mrs. Jones history might look something like this:
The most complete ROS involves asking symptom related questions. Instead of asking “do you have any cardiovascular problems”, you would ask a series of questions such as “do you have an irregular heart beat” and “have you had any chest pain.” ROS is commonly confused with PMH (Past Medical History). ROS is only symptom related, not diagnosis related. For example, diseases such as hypertension and diabetes are listed in the Medical History, not in the Review of Systems. Symptoms, such as dizziness and headaches, are listed in the Review of Systems. Think of the "S" in ROS as meaning "symptoms" instead of "systems".
Some common systems groupings are as follows, with some common questions:
Many offices have a detailed form that the patient completes in the waiting room, thus saving “chair time”. The doctor, the technician, or both, should initial and date the form indicating that it was reviewed.
This includes the Past Ocular History (POH), Past (systemic) Medical History (PMH), and Past Surgical History (PSH). Currently treated and past medical conditions, illnesses, injuries, and surgeries should be recorded. You should record the year of onset or occurrence of older incidents, and the month and year of more recent entries. Ask specifically about eye surgeries such as cataract surgery, refractive surgery, muscle surgery, or retina surgery or treatment.
The eye doctor will be particularly interested in knowing any blood thinning medications the patient may be taking. These medications can increase the tendency of the eye to bleed in disease processes and during surgery.
It is also helpful to ask if the patient has been able to use the medication as scheduled. This is called "compliance". Non-compliance is a big problem in the world of medicine. If a medication is ineffective, the doctor wants to know if the patient is actually using the medication as prescribed.
An allergic reaction and an adverse reaction are not necessarily the same. A person can have an adverse reaction without having an allergic reaction. An allergic reaction is potentially more dangerous than a non-allergic, adverse reaction. An example of a non-allergic, adverse reaction would be nausea following the injection of fluorescein dye. The nausea is unpleasant, but the patient will not die from it. The patient who experiences itching, hives, and a constricted airway is experiencing a potentially life threatening allergic reaction.
Some of the questions that you ask are determined by what kind of problem the patient has. There are “pertinent questions” that are specific questions to ask in regard to symptoms or type of exam. Pertinent questions are questions that the ophthalmologist is going to want answers to, and the doctor will have to ask them if you do not. These questions may speed the examination process by pointing in a particular direction, or they may help the doctor arrive at a diagnosis. The common diseases in each subspecialty each have their own set of pertinent questions. These are learned from experience and a knowledge of ocular diseases, and/or they can be learned from a "cookbook" of questions to ask for specific chief complaints.
Take the example of the patient complaining of floaters. Although floaters are often the benign occurrence of small opacities in the vitreous gel, floaters can be specks of blood in the vitreous secondary to the the vitreous tugging on the retina, possibly causing a retinal tear and potentially a retinal detachment. Vitreo-retinal traction is often accompanied by light flashes in the vision. If a tear has progressed to a detachment, the patient may see a shadow or a veil in the vision of the affected eye. Floaters associated with a retinal tear often come suddenly, and in mass, as opposed to a few benign floaters. Retinal tears and detachments occur more frequently in those patients who are nearsighted. Vitreo-retinal traction and bleeding occurs more often in diabetics secondary to diabetic retinopathy. This knowledge will guide you to pertinent questions.
For this patient, pertinent questions would include:
1. When did you first notice floaters?
2. Did they appear suddenly?
3. In which eye?
4. Are there many floaters, or just a few?
5. Did you see any light flashes at the time the floaters appeared?
6. Do you still see light flashes? How often?
7. Is your vision affected?
8. Do you see a curtain or veil in your vision?
9. Are you diabetic?
10. Have you ever had any eye disease or treatment?
11. Are you nearsighted? (You would want to get more precise information by reading the patient's glasses prescription. If the patient has had refractive surgery, you would want to ask if the patient was nearsighted before the surgery, and if so, the degree of nearsightedness. The degree of nearsightedness can be estimated by asking how good the vision was when not wearing glasses or contact lenses.)
12. Do you have any family history of eye disease?
Notice that pertinent questions cut across the different categories or classifications of the history. Some have to do with the chief complaint, others with the medical history, family history, or other categories.
When documenting pertinent questions, you want to record a response to each question either positively or negatively. This way, the reviewer knows that the question was asked. For example, suppose the following was the recorded history from a patient asked the above set of questions:
"Patient complains of a few floaters that appeared suddenly two days ago in the left eye."
You would not know if the patient had been asked all the questions or not. A more comprehensive record would look like the following:
"Patient complains of a few floaters that appeared suddenly two days ago in the left eye. Pt denies having flashes or any change in vision. No significant eye, health, or family history."
More examples of pertinent questions are listed at the end of this document.
Every patient should be able to rest assured that the information regarding his or her exam will be communicated only among authorized personnel in your office or clinic, unless the patient requests otherwise in writing. This means that it cannot be released to a relative, another doctor’s office, a doctor outside of your practice, or to anyone else without the patient’s written permission. We should all avoid gossiping about patients to fellow employees. Aside from breaking the spirit of confidentiality, gossiping is extremely damaging to the reputation of your organization should a patient overhear it.
HIPAA stands for the Heath Insurance Portability and Accountability Act of 1996. Although the main focus of the act was regulation of health insurance, a byproduct has been the regulation of how all medical records are handled in terms of patient privacy. Fortunately, the standards can be figured out by applying some common sense. Although some of the standards seem a bit nitpicky, they are all designed to safeguard patient privacy. Just keep in mind that if there seems to be a chance that an information "leak" can occur, then there is probably a regulation that addresses the situation. Your office or clinic may require you to attend some type of HIPPA training that can be very extensive. It is beyond the scope of this article to cover all of the possibilities, but here are a few situation that will give you an idea of what you should be thinking about in terms of patient privacy:
The above list is not exhaustive, but it gives you a good idea of the extent of the regulations.
Triage is the term for the procedure you follow when a patient calls regarding an urgent or emergency situation. The term originated with the medical care of wounded soldiers during or after battle. One medic would quickly inspect each casualty and would route the soldier to a specific area according to the severity of the wound(s). Those soldiers with terminal wounds or slight wounds would not receive any immediate attention. Those soldiers needing immediate attention to save their lives would be among the first to be seen.
Triage in the ophthalmologist's office or clinic is not usually so dramatic, and the duty may fall upon a designated technician, or a specially trained receptionist or scheduler. The job requires some knowledge of ocular disease and treatment, and the procedure will vary somewhat according to the preferences of the doctor. The most common reasons for emergency calls to the office are pain, redness, and/or decreased vision, but the triage person needs more information to sort out how urgent the situation is. Here are some general guidelines for triage:
1. We will define an emergency as a situation calling for an immediate trip to the doctor's office or a trip to an emergency room. An urgent situation would call for a same day, or next day appointment in the office or clinic.
2. Acute pain associated with eyeball redness, or blurry vision, or contact lens wear, or injury would be an emergency. Acute pain associated with a surgical procedure that does not usually have post-op pain would also be an emergency. Acute pain following a scleral buckle procedure or a retinal cryopexy procedure may not be an emergency situation because pain following these procedures is common, but the patient is usually given a prescription for a pain medication. Acute pain associated with a lid lesion such as a chalazion is not an emergency situation.
3. Chronic pain or discomfort in or around the eyes might be associated with dry eyes, blepharitis, eyestrain, allergies, or light sensitivity. These are not emergency situations and may not be urgent depending upon the degree of discomfort.
4. A sudden decrease in vision, not associated with pain or redness, must be treated as an emergency situation because a retinal detachment can be the cause. As a screener, you could ask about floaters and flashes or other symptoms, but you are wasting your time, because a lack of these symptoms does not rule out a retinal detachment.
5. What about the person who suddenly discovers poor vision in one eye because the "good" eye is closed or occluded? The vision has probably been decreasing over a period of time and the person has just not noticed it until the other eye was covered, but not necessarily. This situation should be treated with a same day appointment if possible, or perhaps the next day, in other words, as an urgent situation.
6. A gradual decrease in vision is not usually an emergency situation.
7. A new complaint of distorted vision or a central blind spot should be treated as an urgent situation, with an appointment the same day if possible. Macular degeneration responds best to treatment initiated early in the process. If your doctor does not treat macular disorders, it is best to refer the patient to a doctor who does, without the intermediate stop in your office.
8. A chemical splash into the eyes is an emergency situation, but the first response should be initiated by the patient or someone nearby. The eyes must be flushed with a copious amount of water immediately, no matter what the chemical. Many work areas are now required to have an eye irrigation station. After the initial irrigation, the patient should be seen in the office or clinic, or in an emergency room.
This listing will give you an idea of what you should be asking. The individual lists may not be comprehensive for the particular disease, and the questions will vary depending upon what your eye doctor wants you to ask.
1. Does glare bother you, especially when driving at night?
2. Does blurry vision limit your activities, especially reading and driving?
New patient with history of glaucoma:
1. How long have you had glaucoma?
2. Who diagnosed glaucoma?
3. Do you use eye drops? If the patient uses glaucoma drops, you will want to know how he/she has been instructed to use the drops, the last time that the patient used the drops, and the patient's compliance with the drop schedule. For example, the patient never misses a drop (100% compliance), or the patient only remembers half the time (50% compliance).
4. Have you had laser treatment for glaucoma? What kind?
5. Have you had surgery for glaucoma? Which procedure?
6. Has anyone in your family had glaucoma? If so, did the person use eye drops, have laser treatment, or have surgery for the glaucoma? Did the person go blind from the glaucoma?
7. Do you have high or low blood pressure, diabetes, thyroid disease, or high cholesterol?
8. Do you use a tobacco product or do you consume alcohol? If so, how much?
9. Have you had any eye trauma?
10. Are you now, or have you in the past used a steroid medication?
11. Are you nearsighted? (Preferably, more precise information can be obtained by reading the patient's glasses or by performing a refraction. If the patient has had refractive surgery, you may need to rely on what the patient can tell you.)
Established glaucoma patient in for a follow-up visit:
1. Are you having any eye pain or redness?
2. Has there been a change in your vision?
3. Has there been a change in your health?
4. Have you been using your drops as instructed? If not, how have you been using them?
5. Are you having any problems with your drops?
1. Do you have any family history of retinal detachment, macular degeneration, or other retina disease?
2. When did you start having problems with your vision?
3. Did you notice a sudden change in your vision, or was it gradual?
4. Do you notice any distortion in your vision, such as straight lines looking crooked?
5. Are you having problems with one eye, or both?
6. Have you ever been told by another doctor that you have a retina problem? If so, when?
7. Have you ever had any treatment for a retina problem?
8. Are you taking any vitamin supplements for your eyes?
9. Are you taking any blood thinning medications?
10. Are you being treated for high blood pressure or diabetes?
11. Are you now, or have you ever taken Plaquenil?
12. Do you smoke?
13. Do you take a birth control medication?
1. What is your average fasting blood sugar reading?
2. What was your last A1C reading?
3. Is your blood sugar well controlled?
1. Do you have a history of skin cancer?
2. Has there been a prior attempt at removal or biopsy?
3. Has there been any bleeding from the lesion?
4. Has there been any lash loss?
Motility (double vision) problems:
1. Is the double vision vertical, horizontal, or a combination?
2. Does the patient still have double vision when either eye is closed (monocular or binocular double vision)?
3. Does the degree of image separation change with the position of gaze (comitant or incomitant)?
4. Is the double vision present when glasses are worn?
5. Is there a history of childhood strabismus or muscle surgery?
6. Has there been a prior stroke or neurological disorder?
7. Is there a lid droop?
8. Is there a prism correction in the glasses?
1. Has there been prior surgery on the lids?
2. Is there any double vision?
3. Is there any oral or facial weakness?
4. Is there a family history of ptosis?
5. Is there any history of "jaw wink" (the upper eyelid jumps when the patient is chewing or talking)?
1. Do the tears overflow onto the face?
2. Is there any history of lacrimal, nasal, or sinus surgery?
3. Is there any history of facial fracture?
4. Is there any history of dacryosistitis (tearduct infection)?
Entropion (eyelashes turn inward)
1. Has there been any prior eyelid surgery?
2. Is there any history of skin disease?
3. Does the patient pull out lashes at home?
Thyroid eye disease:
1. When was thyroid disease diagnosed?
2. How was the thyroid disease treated?
3. When did the eyes become involved?
4. Do the eyes bulge?
5. Do you have double vision?
6. Do your eyes close all the way when sleeping?
7. Do you have any blurry vision, eye pain, or tearing?
In addition to the usual CC and HPI, the following information may be needed for insurance purposes:
1. Were you wearing safety glasses?
2. Did the injury occur on the job?
3. What was the exact date and time of the injury?
4. What were you doing when the injury occurred?
5. How did the injury occur?
1. Date of trauma if trauma related?
2. Do you have any eye pain?
3. Do you have any pain associated with opening your mouth?
4. Do you have any double vision?
5. Do you have any facial or teeth numbness?
6. Have you had cancer?
7. Have you had any previous orbital surgery?
1. When was the eye removed?
2. Why was the eye removed?
3. Is there an orbital implant?
4. When was the prosthesis made and who made it?
5. Has there been any surgery since the eye was removed? If so, when, why, and what was done?
6. Does the prosthesis fall out easily?
7. Is there any discharge from the socket?
8. Are there frequent socket infections?
1. Do you wear conventional hard. lenses, gas permeables, or soft lenses?
2. Do you wear toric, bifocal, or another type of specialty lens?
2. How many hours do you wear the lenses?
3. Do you wear the lenses while sleeping?
4. How many years have you worn contact lenses?
5. Are you wearing the lenses now? If not, when was the last time you wore them?
5. How do take care of your lenses? What solutions do you use?
6. For the Presbyope wearing contact lenses: What do you do for reading? Monovision? Glasses over the contact lenses? Bifocal contact lenses?