History Taking|Clinical Optometry

Hello all,

This is my first post on clinical optometry. This page comprises all those activities which we do in regular basis. Diagnosis starts when a person enters to chamber. The first stage of evaluation which includes observation, taking history. A detailed communication with the patient always leads us to a right diagnosis. The communication needs to be bi-way always.

We need to first the person’s name, age, contacts, address. A brief demographic data always gives a proper identification and referral in future. After this talk to the person let the patient feel comfortable first. Let the person talk relative. From my personal experience sometimes people starts saying something else, but be calm and listen to the person.

After a patient listening the statement of the person, start asking relative specific questions which will lead you to a specific answer and build the background of your diagnosis. Keep on noting down those points. This notes clinically called as history taking.

Clinical history taking in Optometry comprises: Chief Complaints, Associated Complaints, in regular procedure you can note it down under the heading of “C/O”, which means “complaints of”. The history should be followed by ocular history, systemic history, present medications with doses since when, any kind of surgical history.If any, date should be mentioned with the details of the surgery in brief.We need to remember that whatever we are asking and the patient is responding each and every point we need to document. Each and every point is important which guides us for a right diagnosis.

hope this is informative. Feel free to comment.

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