Competency: 6

Details

Obtain a comprehensive ophthalmic history from the patient To include:

• a patient presenting with ocular and/or visual symptoms and no previous history of vision disorder
• a patient with recurring symptoms

Considerations

• The importance of introducing yourself and your colleagues and explaining to the patient their own role and responsibility in taking patient history
• The importance of accurately recording all information gathered, including relevant dates and the implications of missing, incorrect or invalid information
• The importance and relevance of information, including history of patient past ocular diseases, conditions and surgery to the eye or ocular adnexae; family history of diseases, in particular those affecting the eye or vision; any current and past problems relating to general health, including any surgical procedures
• Other important information and its relevance, including:
  • occupation of patient
  • relevant details of patient’s social circumstances and special needs
  • birth history where appropriate
  • any known allergies or other adverse reactions
  • current medications (prescribed and self-purchased) for any ocular and other medical conditions
• How to verify all information obtained and the importance of name, signature, date and time on the entry
• Requirements for security and confidentiality of patient information, including verbal, written, electronic and imaging data

Relevant learning outcomes