History Taking/Triage/Documentation

Question 1

Greeting

Answer 1

Identifying/Introduce yourself
Explain your role in the exam
Identify person(s) accompanying the patient (HIPAA)

Question 2

Chief Complaint

Answer 2

Purpose of visit recorded in the patient’s own words

Question 3

History or present illness (HPI)

Answer 3

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)

Question 4

Past ocular history

Answer 4

Eye glasses-refraction stable
Contact lens wear
Any previous eye surgery
Any ocular trauma, or eye disease
Infections

Question 5

Ocular Medications

Answer 5

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)

Question 6

Past medical History

Answer 6

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 History

Question 7

Systematic medications

Answer 7

Prescribed medications
     Dosage
     Strength
     Duration
     Compliance
Over the counter medications/suppliments
     Dosage 
     Strength
     Duration

Question 8

Social and Vocational History

Answer 8

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/children

Question 9

Family History

Answer 9

Ocular history

Systemic

Question 10

Allergies

Answer 10

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

Question 11

Scribe

Answer 11

Recording either in written form or electronically “verbatim” what the physician states while examining the patient.

Question 12

Necessary documentation

Answer 12

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.

Question 13

Complete

Answer 13

Statement and signature by the physician verifying that he/she indeed stated what was recorded and that the ophthalmic technician did record it

Question 14

Telephone triage

Answer 14

Gather information

Determine the urgency of patient’s complaint

Question 15

Proper triage is critical

Answer 15

An error in judgement may cause:
Pain and suffering
Loss of vision
Potential legal problems

Question 16

Gathering information

Answer 16

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

Question 17

What information is needed?

Begin the triage process by recording patient’s answer to these questions:

Answer 17

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?

Question 18

Triage

Answer 18

prioritization of patient care (or victims during a disaster) based on illness/injury, severity, prognosis, and resource availability.

Question 19

Emergent problems

Answer 19

True ocular emergencies-see as soon as possible

Question 20

Urgent problems

Answer 20

Need same-day appointment

Question 21

Priority Problems

Answer 21

Appointment within days

Question 22

Routine problems

Answer 22

Routine appointments

Question 23

Emergent problems-tru ocular emergencies (ask patient to come to office immediately)

Answer 23

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

Question 24

Sudden loss of vision-painful

Answer 24

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

Question 25

Sudden loss of vision-painless

Answer 25

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

Question 26

Sudden loss of vision, painless with flashes, floaters

Answer 26

Suspect retinal detachment May see veil or curtain Loss of field of vision

Question 27

Penetrating Injury

Answer 27

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

Question 28

Chemical Burns

Answer 28

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

Question 29

Acute proptosis (bulging or protruding eyeballs) with loss of vision

Answer 29

Accompanied by fever and malaise | Need to rule out orbital cellulitis

Question 30

Blunt trauma with sudden loss of vision and proptosis

Answer 30

Need to assess for retrobulbar hemorrhage | Needs urgent canthotomy/cantholysis to release orbital pressure

Question 31

Sudden loss of vision with headache

Answer 31

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.

Question 32

Sudden onset of diplopia with headache

Answer 32

Associated with ptosis and a 'blown' pupil | Need to assess for aneurysm compressing the oculomotor nerve

Question 33

Urgent problems-same day appointment

Answer 33

``` 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 ```

Question 34

New onset flashes and floaters

Answer 34

Suspect retinal detachment Often benign vitreous detachment Requires dilated exam

Question 35

Blunt Trauma to the eye

Answer 35

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

Question 36

Sudden onset of double vision

Answer 36

``` 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. ```

Question 37

Red eye (may be minor problem or serious; many red eyes warrant a same-day appointment)

Answer 37

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.

Question 38

Protrusion of an eye

Answer 38

One or both eyes Painful or painless Sometimes accompanied by double vision Suspect thyroid disease, tumors or orbital pseudo tumor

Question 39

Contact lens problems

Answer 39

New onset of pain, redness, discharge, photophobia (very sensitive to it), poor vision or change of vision

Question 40

Priority problems-should be within days of their initial complaint

Answer 40

``` Slow disease Progression Gradual, painless decrease in vision Lid problems Lost or broken eyeglasses Ocular Migraines and headaches ```

Question 41

Slow disease Progression

Answer 41

(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

Question 42

Gradual, painless decrease in vision

Answer 42

Suspect cataract or macular degeneration Chronic open-angle glaucoma can be priority appointments unless new pain, redness, severe headaches or seeing rainbows around lights

Question 43

Lid problems

Answer 43

lumps and bumps; often caused by styes, etc. Associated blepharitis rare malignant lesions

Question 44

Lost or broken eyeglasses

Answer 44

Patients unable to function | May need only limited appointment

Question 45

Ocular Migraines and headaches

Answer 45

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

Question 46

Routine-make a routine appointment

Answer 46

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

Question 47

When in doubt

Answer 47

Check with doctor for guidance Err on side of safety Schedule patient ASAP

Question 48

Gradual loss of vision

Answer 48

Ametropia (increase or change in refractive error) Media opacitiesL mucus, cornea, aqueous, lens, vitreous Receptor defect; Retina, optic nerve, chiasm, occipital cortex

Question 49

Sudden loss of vision lasting >1/2 hour

Answer 49

``` Optic neuritis Occlusion of central retinal A or V Vitreous hemorrhage-often diabetic retinopathy Retinal Detachment Hysteria ```

Question 50

Sudden loss of vision lasting <1/2 hour

Answer 50

Amaurosis fugax: transient ischemic attack (elderly) | Ophthalmic migraine: Occurs in second and third decade (not limited to)

Question 51

Halo

Answer 51

Glaucoma and other causes of corneal edema Cataracts or conjunctival secretions (infrequently) Post laser vision correction (LASIK or PRK)

Question 52

Curtain

Answer 52

Retinal Detachment or hemorrhage Amaurosis fugax Ophthalmic migraine

Question 53

Flashes of light

Answer 53

Retinal: Vitreous traction or trauma to retina Occipital: Migraine headache

Question 54

Nyctalopia (night blindness)

Answer 54

Retinitis pigments Other degenerations of rods receptors Vitamin A deficiency

Question 55

Spots

Answer 55

Muscae volitantes Scotoma corresponding to defective area of retina corneal foreign body

Question 56

Diplopia

Answer 56

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

Question 57

Asthenopia (eye fatigue)

Answer 57

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

Question 58

Ocular tenderness

Answer 58

Episcleritis, endophthalmitis Markedly elevated intraocular pressure Lid or orbital inflammation Scleritis

Question 59

Photophobia

Answer 59

``` Uveitis Albinotic and lightly pigmented eyes Keratitis Conjunctivitis (infrequently) Corneal abrasion ```

Question 60

Gritty Foreign-body sensation

Answer 60

``` Conjunctivitis Ocular foreign body Corneal Abrasion Dry eye syndrome Trichiasis ```

Question 61

Itching and burning

Answer 61

Conjunctivitis-especially allergic | Occurs with asthenia