Clinical Pearls in Optometry: History Taking

This on-going series of articles covers all the various aspects of a clinical eye examination and adopting an evidence based approach for clinical decision making.  Subscribe to our newsletter or follow us on LinkedIn and Facebook for more on how you can develop your clinical practice and explore specialisation within the field of Optometry.

Why is History Taking important?

Taking a comprehensive clinical history at the beginning of an eye test is essential for successful clinical decision-making as well as for creating a foundation for a longstanding patient-practitioner relationship. The five-minute conversation at the start of the test will create a rapport with the patient and allows them to communicate their eye health-related issues. The aim of taking a history is to elicit the patient's reason for visit, ascertain their expectations and acquire relevant background information, resulting in the formation of a tentative diagnosis.

A systematic approach to history-taking ensures that all bases are covered and nothing is missed. It may not occur to the patient to volunteer relevant information, therefore, it is important to ask. A comprehensive history can be divided into sections, each section following the previous one in a logical order. It is important to address immediate concerns before digging further into the patient's background.

History Taking in Eye Care

1. Demographic Data: Patient's name, age, biological gender and race.
2. Reason for visit: The patient could be attending the clinic for one of several reasons including, symptoms such as blurred vision, headaches or red eyes, an eye test for medical purposes, a glaucoma test or just a routine eye test to perhaps get a new pair of spectacles or contact lenses. Asking about their last eye examination is also useful to determine their awareness about the health of their eyes.
3. Symptomatic History: If the patients reports any symptoms such as those mentioned above, getting further details regarding the symptoms can narrow down which investigations are to be conducted and aid in reaching a diagnosis faster. The 'FLOADS' criteria is a logical approach to further questioning: Frequency Location Onset Association Duration Severity. "FLOADS" can be applied, in context, to any reported symptom.
4. Ocular History and Medications: If the patient has any existing eye conditions such as glaucoma or dry eyes, for which they might be taking eye drops, if they wear cosmetic or therapeutic contact lenses or previous hospital eye treatment, including surgery, infections or injury to the eyes.
5. Systemic History and Medications: If the patient has any systemic conditions such as diabetes or hypertension, which can potentially affect the eyes, or if they are on any medications that may have ocular side effects.
6. Family Ocular and Systemic History: It is well documented that those with first degree relatives that have conditions such as glaucoma or diabetes are at a higher risk of developing those conditions, therefore they must be screened accordingly.
7. Lifestyle: The patient's occupation, hobbies and habits (driving, smoking, alcohol etc). This information gives the practitioner an idea about visual tasks in the patient's daily lives, such as screen time and time spent outdoors, which need to be taken into consideration while prescribing spectacles or contact lenses.

Conclusion

A history can be noted down on a paper record or recorded electronically.  A good EMR software should offer a seamless history taking module, which involves minimum typing, while also covering all the aforementioned sections to ensure no details are missed.

ASIRA is a simple and secure, cloud-based software tool, built BY optometrists FOR optometrists, that helps eye care professionals reduce the time and effort required to maintain clinical records, schedule appointments, generate bills, manage inventory and much more!

To find out more, visit www.asira.health and sign up for a 30-Day FREE TRIAL! If you're a new practice owner or a fresh graduate thinking of entrepreneurship, visit www.asira.health/optompreneur to learn how ASIRA can help reduce your costs and increase revenue.