Prior to starting the history, you will want to ask the patient their demographic information:

Name _________

Race __________

Age ___________

HISTORY:

You will always want to introduce yourself and explain what you are going to do with the patient.

Chief Complaint:

“What brings you in today?”

O: onset

“When did that first begin?”

“How long have you noticed this?”

P: provocative, palliative

“Does anything seem to make that better?”

“Does anything seem to make that worse?”

“Do you notice this more with any activities? Less?”

Q: quality

“describe” “can you describe it to me?”

R: radiation/region

“do you notice this in one eye or in both eyes?”

S: severity/scale

“_/5” “On a scale of 1 to 5: with 1 being it does not impact

your daily activities at all and 5 being it impacts almost all of them, how would you rank this?”

T: timing, duration

“do you notice this during a certain time of the day?”

“is it constant or does it come and go?”

“how long does it last?”

Notes about HPI

• Be specific and descriptive with your language.
• Follow a logical timeline/chronology.
• Be as specific as possible when describing symptoms.
• Use patient’s own words whenever possible and quantify whenever possible.
• Avoid using unconfirmed diagnoses in the HPI.
• Report physical examination findings (not diagnoses which belong in the assessment).
• Record information as objectively as possible without interpretation.

Blur

You will want to ask the patient and properly record distance and/or near blur.

+/- D blur

+/- N blur

Note:

If the patient’s chief complaint above did not mention any distance or near blur, you will want to investigate the blur by asking TADED: timing, association, duration, eye and description.

If the patient’s chief complaint mentioned distance blur, but not near, you would record a + D blur and ask about N blur. You would apply the same logic if the patient noted N blur in their chief complaint.

POHx:

Last Eye Exam (LEE)? By whom, Dilation?

Note: You will want to explain “dilation” to the patient by asking “at that appointment, did the doctor dilate you by putting drops in your eyes that made your pupils large and  sensitive to light?”

+/- SPRx:

“How long have you worn glasses?”

How old is the current pair?”

“What do you use them for?”

“FTW?”

+/- CLRx:

“Type of CLs?”

“How often replaced?”

“Brand?”

“How old are current lenses?”

“Avg wear time? Max wear time? Today’s wear time?”

“Sleep/nap in CLs?”

“Solution brand?”

“Do eyes dry out?  After how long?”

“Does vision fluctuate with CLs?”

Infection, Trauma, VT

Refer to intake form for infection, trauma, VT:

If no, confirm.

If yes to trauma or infection:

W: When? aka “When was this?”

E: Which eye? aka “Which eye was this in?”

T: Treatment? aka “Did you have any treatment?”

C: Compliant with treatment? aka “Did you follow Dr’s orders for that tx?”

L: Lasting effects? Recorded as Sequela aka “Do you have any lasting effects?”

If yes to VT: ask the W’s aka “When? Why?”

Note:

When talking to the patient, do not use the words “trauma”, “amblyopia” or “visual training”. Instead of visual training or amblyopia, ask the patient if they have ever patched their eye. Instead of trauma, ask the patient if they have had any eye injuries.

HA & Present Visual Symptoms & 2 CC:

“Have you recently had any: ______”

(Note: Recently = last few months)

+/- HAs, halos, photopsia (“flashes of light”), diplopia (“double vision”), floaters, seizures

If yes, T: timing“when did this start?”

A: association“do you associate this with anything?”

D: duration“how long does it last?”

E: eye“which eye?”

D: description “can you describe it for me?”

C: changes“have you noticed changes recently?”

If no, (-)

PMHx:

LPE: date and doctor (refer to intake sheet and record)

General health: “how is your general health?”

BP: “ __/__ or describe” (date) “at that last exam, did they check your blood pressure?”

Cholesterol: “describe” (date) “and did they check your cholesterol?”

Any recent fever, fatigue, unexpected weight gain/loss? (refer to intake form and record)

Any surgeries? (refer to intake form and record)

Are you being followed by your doctor for anything? (refer to intake form and record)

How often followed?

How long?

Treatment?

Controlled?

If the patient is female and under 50 years of age: -/+ pregnancy or nursing?

KMA/KEA:

-/+ KMA

-/+ KEA

What? Rxn? When discovered? Tx?

Medications: Rx or OTC:

+/- Rx drugs?

+/- OTC drugs?

+/- Eye drops?

Name? Taken for? Since when? Dosage? +/- compliance? Side effects?

For OTC drugs: Who recommended it to you?

FxHx: Family Systemic & Ocular

Refer to intake form. If checked yes, ask:

Who?

Age when diagnosed?

Treatment?

Controlled?

Occupation/Hobbies/CRT Use

Occupation? (refer to intake form)

Hobbies?

CPU? “How many hours per day do you use a computer? Any problems with your vision?”

Reading? “How many hours per day do you spend reading/near work? Any problems w/ vision?”

+/- Alcohol? Tobacco? Recreational drugs?

Frequency?  Amount?

Additional Comments:

Pleasant, Appropriate, Oriented x3

SUMMARY

Give your patient a 15-20 second summary of their history

Try to summarize the “+”s of the history but be sure to confirm allergies, medications, and pregnancy/nursing for females.

Ask if they have anything else they would like to add/discuss

TENTATIVE DX

Based on the patient’s chief complaint and history, write your tentative diagnosis. (NOTE: this is not something that you’d write on a history in clinic, but is expected for the proficiency.)

SIGN

COMMONLY USED ABBREVIATIONS