Training activity information
Details
Take a full medical and ophthalmic history from patients
Type
Entrustable training activity (ETA)
Evidence requirements
Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion.
Reflection at multiple timepoints on the trainee learning journey for this activity.
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
- What does success look like?
- Identify what is expected of you in relation to taking a full medical and ophthalmic history from patients. Consider how the learning outcomes apply, including constructing appropriate histories, employing effective communication and producing clear, concise and accurate documentation.
- What does a successful medical and ophthalmic history look like for a patient in the visual pathway context, considering factors like identifying common ophthalmic and non-ophthalmic medications and their potential impact on vision, understanding the importance of birth history and developmental milestones in paediatrics, and identifying common medical and ophthalmic conditions and their potential impact on the patient and their vision?
- Discuss with your training officer to gain clarity on what is expected of you in taking a full history.
- What is your prior experience of this activity?
- Think about what you already know about taking patient histories, interviewing techniques, and documenting information.
- Consider possible challenges you might face, such as communication barriers, patients with complex medical histories, difficulty eliciting necessary information, or knowing which specific details are most relevant to visual pathway assessment and think about how you might handle them.
- Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom, regarding complex histories or sensitive information.
- Acknowledge how you feel about taking a full patient history.
- What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop in taking comprehensive and relevant histories for visual pathway patients – drawing upon previous experiences.
- Identify specific insights you hope to gain, perhaps regarding how patient history directly informs the selection and interpretation of visual pathway tests or enhancing communication techniques for different patient groups.
- What additional considerations do you need to make?
- Consult actions identified following previous experience of taking histories or similar patient interactions, if any.
- Identify important information you need to consider before embarking on the activity, such as specific questions relevant to common visual pathway conditions, potential red flags to look out for, and local documentation standards.
In action
- Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate while taking the medical and ophthalmic history?
- Are you encountering situations such as:
- The patient revealing a particularly complex medication list or medical background that was not anticipated?
- The patient mentioning an unexpected condition or symptom that significantly impacts their vision, requiring immediate redirection of your questioning?
- A significant communication challenge (e.g., emotional distress, language barrier, difficulty recalling critical details) making the information gathering much harder than expected?
- How is this experience comparing with previous experiences of similar activities, such as taking histories in other settings?
- How are you reacting to the unexpected development?
- How is this impacting your actions? Did you adapt or change your approach to questioning or communication style in the moment?
- Consider the steps you are taking in the moment, such as:
- Immediately modifying your line of questioning to accurately explore the impact of an unexpected condition on the patient’s visual symptoms?
- Adapting your questioning style or using validation techniques to address unexpected psychosocial issues or patient distress that emerged during the history taking?
- Are you seeking immediate advice from a supervising colleague regarding a complex or sensitive part of the history to ensure you stay within your scope of practice?
- How are you feeling in this moment? For instance, are you finding it difficult to adapt? Is it affecting your confidence in adjusting the line of questioning? Do you feel positive you can reach a successful conclusion?
- What is the conclusion or outcome?
- Identify how you are working within your scope of practice when taking the history. Did you successfully manage sensitive information while maintaining adherence to documentation standards?
- What are you learning as a result of the unexpected development? For example, are you learning a more effective technique for eliciting sensitive information or gaining a crucial insight into how complex medication lists should be documented concisely?
On action
- What happened?
- Begin by summarising the key points of the experience of taking the medical and ophthalmic history.
- Consider specific events, actions, or interactions that felt important during the history taking, such as managing a complex medication list, eliciting sensitive birth/developmental history for paediatrics, or dealing with the impact of medical/ophthalmic conditions on vision. How did you feel during this experience?
- Include any ‘reflect-in-action’ moments, where you had to adapt to the situation as it unfolded while taking the history, for instance, modifying your questioning approach or communication style.
- How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience regarding constructing an appropriate history.
- What strengths did you demonstrate (e.g., efficiency in information gathering, empathetic communication, adherence to documentation standards)?
- What skills and/or knowledge gaps were evident (e.g., unfamiliarity with specific ophthalmic conditions, difficulty tailoring questions based on patient age, or gaps in producing clear, concise, and accurate documentation)?
- Compare this experience against previous engagement with similar activities, like taking histories in other settings. Were any previously identified actions for development achieved? Has your practice in history taking improved?
- Identify any challenges you experienced during the history taking (e.g., patient resistance, language barriers, complex medical backgrounds) and how you reacted to these. Did this affect your ability to deal with the situation? Were you able to overcome the challenges?
- Identify anything significant about the activity, such as needing to seek advice or clarification regarding the patient’s history or needing to escalate to ensure you were working within your scope of practice when obtaining the history.
- Acknowledge any changes in your own feelings now that you are looking back on the experience.
- What will you take from the experience moving forward?
- Identify the actions you will now take to support the assimilation of what you have learned, including from any feedback you received regarding the accuracy and relevance of your history taking.
- What will you do differently next time you take a history? Has anything changed in terms of what you would do if you were faced with a similar situation again during history taking?
- Do you need to practise any aspect of the activity further? E.g., Practising specific communication techniques or refining documentation methods to ensure accuracy and conciseness.
Beyond action
- Have you revisited the experiences?
- Have you reviewed your actions from your previous reflections for taking a full medical and ophthalmic history from patients?
- What specific actions did you previously identify you would need to take to improve your practice related to communication skills, understanding specific medical/ophthalmic conditions, or knowledge of medications?
- Have you completed these previously identified actions? If so, how did completing them impact your subsequent performance of this activity? Are you ready to demonstrate this new learning confidently and consistently when taking histories?
- How has discussing these experiences with others changed your perspective or approach, or led to transformation?
- How have these experiences impacted upon current practice?
- Consider how the accumulated learning from performing or reflecting on taking histories will support you in preparing for relevant observed ‘in-person’ assessments for the module, such as the Observed Communication Event (OCE) titled ‘Take a full history from a patient’.
- How has your practice related to taking medical and ophthalmic histories developed and evolved over time?
- This includes recognising when obtaining a history is beyond your scope of practice and when you need to seek advice or help.
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 1 |
Outcome
Construct an appropriate history and symptoms from a patient to inform management decisions. |
| # 5 |
Outcome
Employ effective communication with a range of individuals, including the patient and the multidisciplinary team. |
| # 7 |
Outcome
Produce clear, concise and accurate documentation in line with local standards and legislation. |