History Taking

• What type of information is included in the demographic information of a patient history?

  Name, address, contact numbers, age, occupation, Medicare/pension cards, previous attendance
• Why is demographic information often collected by reception?

  To ensure accurate patient identification and record-keeping
• What are the main components of the patient history structure?

  • Demographic information
  • Presenting Complaint (PC)
  • Screening questions
  • Patient ocular history (POH)
  • Family ocular history (FOH)
  • General Health (GH)
  • Visual tasks (VT)
• What is the purpose of asking about the Presenting Complaint (PC)?

  To understand what has brought the patient in for consultation
• What type of question is typically used to inquire about the Presenting Complaint?

  An open question
• Why is it important to explore multiple problems a patient may have during the Presenting Complaint inquiry?

  Because patients may have more than one issue that needs addressing
• What is the legal significance of the Presenting Complaint documentation?

  It serves as a legal document
• What should be used to document the Presenting Complaint?

  Write in pen or fill it out on a computer
• What are some key abbreviations used in documenting the Presenting Complaint?

  • OD (right)
  • OS (left)
  • OU (both)
  • w/o (without)
  • y/o (year old)
  • x/12, x/52, x/7 (time frames)
• What information should be gathered regarding the time of onset of a problem?

  When the problem was first noticed and the time of day it occurred
• What factors should be assessed regarding the frequency of a problem?

  How often the problem occurs, such as daily or weekly
• Why is it important to ask about the severity of a problem?

  To understand the impact of the problem on the patient's life
• What should be noted about the duration of a problem?

  How long the problem has been occurring
• What is meant by "related to any tasks the patient does" in the context of a Presenting Complaint?

  Assessing if the problem is linked to specific activities the patient engages in
• What are "relieving factors" in the context of a Presenting Complaint?

  Factors that alleviate or reduce the severity of the problem
• What does "associated signs or symptoms" refer to in a Presenting Complaint?

  Other symptoms that occur alongside the main complaint
• What does "progression of complaint" mean?

  Whether the problem is getting worse or better over time
• Why is it important to ask about any previous treatments for the Presenting Complaint?

  To determine if past treatments were effective or not
• What does "idea of cause" refer to in the context of a Presenting Complaint?

  Patient's perception of what may have caused their problem
• What does LOFTSEA stand for in the context of Presenting Complaint documentation?

  • Location/laterality
  • Onset
  • Frequency
  • Type/Severity
  • Self treatment and its effectivity
  • Effect on patient
  • Associated signs or symptoms
• What does COLDER stand for in the context of Presenting Complaint documentation?

  • Character
  • Onset
  • Location
  • Duration
  • Exacerbation
  • Relief
• What are some screening questions to ask if they are not the presenting complaint?

  Questions about vision, sore eyes, red eyes, itchy eyes, flashes, floaters, headaches, and double vision
• What visual tasks should be assessed during the patient history?

  Driving, occupation, hobbies, and VDU hours
• Why is it important to ask about visual tasks?

  To understand the visual demands placed on the patient
• What types of symptoms might patients present with?

  A vast array of symptoms
• What are the main important next questions if a patient presents with flashes and floaters?

  How long do the flashes last and what color are the flashes?
• What should be clarified when a patient reports double vision?

  Whether they see two images side by side or one above the other
• What is the significance of asking about the patient's general health?

  • To assess overall health status
  • History of diabetes, high blood pressure, heart disease
  • Current medications and allergies
  • Smoking habits
  • GP's name and address
• What should be included in the family ocular history?

  • Glaucoma
  • Macular Degeneration
  • Lazy eye/patching (if child)
  • Systemic conditions (diabetes, hypertension, heart disease)
  • High rx or blindness
• What should be included in the previous ocular history?

  • Previous visits
  • Eye operations
  • Eye injuries
  • Eye infections
  • First glasses
  • Previous practitioners
  • Lazy eye (children or adults)
• What are the key components of the general health/medical history section?

  • Open question about general health
  • History of chronic conditions
  • List of current medications
  • Allergies (ocular and systemic)
  • Smoking status
  • GP's contact information
• What is the initial impression a patient gains from the optometrist based on?

  The history taken during the consultation
• How does developing rapport with a patient affect their comfort level?

  It makes patients more comfortable and open, aiding in diagnosis
• What are the outcomes of good communication in patient care?

  Effective and efficient patient outcomes and improved patient safety
• Who should effective communication occur between in a healthcare setting?

  Between patient and optometrist, and among optometrists and referrals
• What does evidence suggest about training students in good communication?

  It improves diagnosis and patient satisfaction, and skills are retained long-term
• What opportunities should be provided to students to practice communication skills?

  Practice with real and simulated patients in controlled conditions
• What role does feedback play in developing communication skills for students?

  Feedback helps refine skills through audio/video and supervision
• What is important during the initial meet and greet with a patient?

  To put the patient at ease and introduce yourself
• Why is it important to address patients by their full title?

  Patients have expectations about how healthcare professionals should address them