Charting: Additional Patient Notes Patient Feedback

Common patient feedback and responses for medications and allergies: Some patients may ask if they can present with the medication list, I would consider that acceptable. I’d be sure to scan in a copy and enter it into the patient’s chart along with documenting appropriately within your EMR.

 

Common patient feedback and responses for past ocular, social, and family history: Sometimes patients may mention a previous injury. What I like to use as a guideline is to mention to them if they were monitored by a doctor at all for the injury, if there was a bandage contact lens used, or if you were prescribed any medication or any drops for that injury.

 

When asking about social history some patients can be very sensitive when you’re asking about this type of information. Again, I would just review as quickly as you can and just remain as professional as possible and answer any questions appropriately.

 

When asking about family history, sometimes the patient may start to mention extended family members. I like to remind the patient that I’m only needing information for immediate family members that are blood relatives that may apply to their health history.

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