What is the main reason why the patient is visiting the doctor, typically documented in the patient’s own words, called?
History and Documentation
Chief Complaint
If it is a follow-up per MD, document what is happening and why.
DELETE/REPLACE QUESTION!!!
Name at least five sections that need to be documented to be considered ‘good’ history taking.
History and Documentation
CC/HPI
Past Ocular History/Ocular Surgical History
Medical/Surgical History
Social History
Family Ocular/Medical History
Medications/Vitamins/Supplements
Allergies
Name at least for categories of ocular history-related questions you may ask the patient.
History and Documentation
History of glasses or contact lens wear
Known eye condition
Surgical history
Trauma history
Current eye drops being used
Current oral medication being used for the eye
Name at least 3 categories of general medical and social history-related questions you may ask the patient.
History and Documentation
Current/past medical history
Current medications
Surgeries/treatments
Tobacco use
Alcohol use
Drug use
Patient’s occupation/hobbies
An APD is noted in the patient’s previous chart notes. Before instilling dilation drops, what should the technician check?
History and Documentation
Full pupil exam including verification of the APD.
Name 3 common medical conditions that can affect the patient’s vision.
History and Documentation
Diabetes
Hypertension
Cancer
Hyperthyroidism
Cardiovascular disease
What is it important to note all prescribed and non-prescribed medication for a patient?
History and Documentation
All medications have side effects and some can even cause blurred vision. It is also important if the patient is going to surgery to be sure none of the medications reduces their ability to clot or cause other complications during surgery.
True or False: You can assume that the person sccompanying the patient during the eye exam is someone to who you may release medical information.
History and Documentation
False, their must be written documentation by the patient in the chart.
How should the technician respond when a returning glaucoma suspect with an IOP reading of 31 mmHg at today’s visit, asks if he has glaucoma?
History and Documentation
Always defer to the ophthalmologist to provide a disgnosis and medical advice.
Define HIPAA.
History and Documentation
Health Insurance Portability and Accountability Act is a set of rules for patient privacy, security of health information, health insurance shifts after leaving an employer. There are severe penalties for non-compliance.
What is the difference between a sign and a symptom?
History and Documentation
A sign is an objective observation noted by the examiner, while a symptom is an observation made by the patient.
History and Documentation
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