Term
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Definition
1. History
2. Prelim testing
3. Refraction
4. Binocular Vision and Near pt testing
5. Ocular Health
6. Assessment and Plan |
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Term
S.O.A.P. = standard for all clinical encounters/records
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Definition
S-- Subjective, CC, and Medical History
O--Objective, all exam observations/findings
A-- Assessment/diagnosis
P--Plan, Treatment, Pt instructions
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Term
| Purpose of problem-oriented exam |
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Definition
| To diagnose and address Pt's complaint |
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Term
Parts of Optometric History (HX)
1. |
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Definition
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Term
Parts of Optometric History (HX)
2. |
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Definition
| POHx--Visual Hx and demands |
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Term
Parts of Optometric History (HX)
3. |
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Definition
| PMHx--Personal Medical HX and ROS (review of systems) |
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Term
Parts of Optometric History (HX)
4. |
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Definition
| FMHx-- Family Visual and Medical Hx |
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Term
Parts of Optometric History (HX)
5. |
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Definition
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Term
Parts of Optometric History (HX)
6. |
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Definition
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Term
Types of Histories
(Problem-Focused) |
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Definition
Brief--need 1-3 questions on CC.
ex)VAs check for drivers test |
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Term
Parts of Optometric History (HX)
(Follow up) |
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Definition
| 1-3 CC questions like problem-focused but include change in symtoms/use of treatements |
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Term
Parts of Optometric History (HX)
(Expanded Problem Focused) |
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Definition
Need 4 or more questions on CC
or
3 or more chronic/inactive problems reviewed
ex) Trauma (include facts surrounding trauma) |
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Term
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Definition
G.O.C.A.A.
Grief
Open
Closed
Anxiety
Anger
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Term
Parts of Optometric History (HX)
(Detailed) |
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Definition
| Expanded Problem Focused and ROS 2-9 |
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Term
Parts of Optometric History (HX)
(Comprehensive) |
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Definition
| Same as Detailed HX, but include 10 ROS |
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Term
Parts of Optometric History (HX)
(Comprehensive Health)
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Definition
| RARE for ODs--All ROS completed |
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Term
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Definition
| Slumped posture, eyes/mouth down, red eyes, responding to loss |
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Term
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Definition
| open legs/arms, relaxed posture, inquisitive expression |
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Term
| length of routine optometric history |
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Definition
10-15 min
**Remember history continues through exam though |
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Term
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Definition
| arms/legs closed, tight posture, accusatory expression |
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Term
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Definition
| tight posture, narrow eyes/stare at interviewer, tight lips, increased breathing rate, flushed appearance |
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Term
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Definition
| fixed head position, wide-eyed expression, guarding posture, small repetitive movements |
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Term
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Definition
*Used when more info needed after pt stops talking
*Repeat pt's last few words in form of question.
*Repeating reflects it back to pt
ex. "You had this eye pain?" |
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Term
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Definition
| Dr. compares signs and symptoms to similar sets of complaints |
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Term
| length of complex optometric history |
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Definition
15-20 min
ex) HAs, Multi-symptom cases, geriatric
**Remember history continues through exam though..NEVER COMPLETE |
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Term
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Definition
Used when word is ambiguous or confusing
ex) Dizziness--what does pt mean by dizzy?
***can give examples to help pt describe |
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Term
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Definition
| Objective--found during exam and recorded in chart separate from history (O of SOAP) |
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Term
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Definition
| Subjective--pt complaint--written as part of history--(S of SOAP) |
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Term
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Definition
Recognizing/acknowledging pt's feelings
Use to show pt your are ok w/their feelings
ex) "this must be difficult for you" Or Meetz's handicapped pt who tore $300 CL. |
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Term
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Definition
Statement used to show discrepancies, esp in affect
ex)"you say all is resolved, but you sound angry" |
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Term
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Definition
Based on inference--NOT observation--link statements to imply cause
ex)it seems every time you wear CLs, your eyes are crusty in the morning |
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Term
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Definition
Explaining to pt why a question is asked
ex) when eyes are red this long we need to ask about activities or symptoms in other parts of the body |
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Term
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Definition
| Condenses facts and conveys how you understand pt's health/vision needs or problems |
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