By Mark Wright, OD, FCOVDand Carole Burns, OD, FCOVD
Managing the patient history is essential to effectively improving the patient’s life at home, school, work and play. An effective way to think of the patient history is to divide it into three categories: demographic history, medical history and lifestyle history.
The demographic history is important for the following reasons:
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You must know how to contact the patient.
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The age and ethnic background helps identify patient risk factors.
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A data sort of the demographic history helps you identify your marketing opportunities.
Because of medical reimbursement documentation requirements, we most often focus on the medical history. The best way to approach the medical history is to use the 99000 E/M approach with its four major categories:
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Chief complaint (Reason for the visit)
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History of present illness (History of the chief complaint)
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Review of Systems (Review of symptoms of the systems: e.g., “Do you have chest pain?”)
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Past, family and social history (at least one question answered for each of the three areas)
The lifestyle history may be the most important part of the total patient history. This part of the patient history gives you insight into the areas where you can improve the quality of life of the patient. Your lifestyle patient history should at least explore the following areas:
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Outdoor activities (ball sports, biking, camping, fishing, gardening, hunting, shooting)
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Indoor activities (chess, cooking, crafts, scrapbooking, sewing, TV)
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Screen activities (computer, digital photography, gaming devices, smart phone, tablet)
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Vision devices (“Do you want to go without glasses or contacts? Do you ever take your contacts out sooner that you wanted? Do you have a pair of polarized sunwear for driving?”)
This week you have two assignments:
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Review how you collect, document and analyze the patient’s history. Make sure you understand how the patient uses their eyes at home, school, work and play so that you can create a treatment plan that improves the patient’s quality oflife in each of those areas.
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Pay close attention to which parts of the history are not collected when the patient is late to the appointment. Come up with a plan to make sure you have the needed information to be able to deliver high quality complete care for every patient you see.
