Physicians gather information from patients related to the onset and development of eye diseases and record it accurately and thoroughly, as this is critical for the diagnosis and treatment of ocular conditions. Key points for medical record documentation include:
Personal Information
This includes the patient's name, gender, age, occupation, address, phone number, and other identifying details.
Chief Complaint
This refers to the primary ocular symptoms and their duration, which help in diagnosing the disease. The chief complaint should specify the affected eye, be concise and precise, and typically consist of fewer than 20 characters, including punctuation.
History of Present Illness
This section covers triggers and onset time, primary symptoms, presence or absence of accompanying symptoms, progression and changes in the condition, any prior treatments received and their effectiveness, as well as any systemic abnormalities occurring during the disease course.
Past Medical History
This includes information on whether the patient has experienced similar ocular conditions in the past, other eye diseases, systemic diseases, history of trauma, allergies, and infectious diseases. It also documents any surgical history, history of ophthalmic or systemic medication use, as well as any history of wearing corrective lenses (both eyeglasses and contact lenses).
Personal History
This part notes lifestyle habits and environments that could be related to the eye disease, along with any special hobbies (such as a history of pet ownership). For pediatric patients, details about prenatal, perinatal, and developmental history are also recorded.
Family History
This section examines whether any family members have had similar conditions. If a hereditary disease is suspected, attention is paid to whether the patient's parents are consanguineous.