Diagnostics

Refine your history-taking skills

Follow these tips to ensure novice techs obtain an accurate history.

BY JENNIFER KIRBY, CONTRIBUTING EDITOR

Patient medical-history taking can be like great art: Include all the “right” elements, and you have a masterpiece. In this case, a pristine chart facilitates diagnosis, management, and patient care along with accurate reimbursement and protection from a chart audit.

With the demands of the ever-growing aging population exceeding the supply of certified ophthalmic techs, ophthalmic practices must hire novice techs. This makes pristine charts harder to come by. New techs can benefit from following these steps.

1. Get tech “buy-in”

Talk with new techs about the importance of patient medical-history taking, so they understand the crucial role they play in the patients’ and practice’s health, explains Ellie Bessarab, COT, part-time tech instructor at Portland (OR) Community College and a part-time tech at Vancouver (WA) Eye Care.

“You should say, ‘You play a pivotal role in the patient’s care because the patient’s medical history dictates the exam,’” she says. “You may even want to provide a brief example to really drive that point home. Also, I would stress the importance of general medical-history taking during this conversation, as some new techs gloss over it, thinking it’s not as important because it doesn’t deal directly with the eye.”

2. Create a “cheat sheet”

Provide new techs with a “cheat sheet,” or a poster in each exam lane, comprised of the necessary medical history-taking components, suggests Janice K. Ledford, COMT (see Key elements of patient history.).

“It [the ‘cheat sheet’ or poster] should contain chief complaint, the eight quantifiers — location, duration, timing, etc. — past ophthalmic history, general medical history, personal, social family history and the number of items that must be included/documented in order for the exam to qualify at a specific level of billing. This way, new techs can ensure no stone is left unturned when interviewing patients,” says Ms. Ledford, a 30+ year veteran ophthalmic tech and ophthalmic tech training author (http://tinyurl.com/ledfordbooks).

Ms. Bessarab says she teaches the mnemonic FOLDARS (Frequency, Onset, Location, Duration, Associated signs and symptoms, Relief, and Severity) to cover the chief complaint quantifiers.

“EHRs contain drop-down menus for the eight quantifiers, which not only help new techs avoid typing errors but also show them that at least four are needed per chief complaint to qualify for reimbursement as an extended exam,” she says. “Also, you can customize a lot of the EHRs out there to ensure a tech’s work is captured. For example, you could create a template that includes ‘new patient’ or ‘established patient,’ so the new tech knows one or the other must be selected to ensure proper data is collected and the exam is billed for accordingly.”

3. Teach medical necessity

As CMS and medical plans pay only for those procedures that fall under “medical necessity,” it’s important you define what does and does not constitute medical necessity, says Ms. Ledford.

“Explain that answers such as, ‘I need stronger glasses,’ to the question, ‘What is your chief medical complaint,’ do not meet the definition of medical necessity,” she explains. “Further, instruct new techs that upon receiving such answers, they should browse the patient’s medical history form or, if the patient is established in the practice, past visits, so a chief complaint that falls under medical necessity can be elicited.”

In using the “I need stronger glasses” example, a new tech may see in the patient’s record that he or she was diagnosed with cataracts. Armed with this information, the new tech could then ask questions related to cataracts, such as, “Are you experiencing any problems with your distance vision?” The answer may be, “blurred vision at distance,” which is a chief complaint that falls under medical necessity, Ms. Ledford explains.

To ensure new techs know the “right” questions to ask to obtain a chief complaint that falls under medical necessity (which enables the ophthalmologist to determine the best course of action), provide a reference sheet. It should contain common eye conditions (AMD, cataracts, etc.), their symptoms, and associated questions for patients, says Jane Shuman, COT, COE, OCS, founder of EyeTechs and co-editor-in-chief of Ophthalmic Professional.

To facilitate learning the “right” questions, consider purchasing patient medical history reference books or recommending patient medical history online courses, says Ms. Shuman. Before providing these recommendations, vet them to ensure they’re reliable.

4. Role-play scenarios

Ms. Shuman recommends having a senior tech pretend to be a patient while the new tech asks patient medical history-taking questions.

“Afterward, the senior tech should go over the scenario with the new tech and explain why some of the new tech’s questions were appropriate, why others should be omitted, what other questions were left out, and why they’re important to ask,” she says.

5. Mandate shadowing

Have a new tech follow a senior tech for a couple days to reinforce the “right” patient questions, says Ms. Bessarab.

“Shadowing a senior tech is also a great way for the new tech to learn how patients should be treated,” she says. “Technology has a way of overshadowing the human aspect of this, and it’s important to note that when a patient tells his or her family about the appointment, the focus is going to be on the experience, not what the doctor said. Essentially, a tech’s actions can determine whether a patient returns and refers others.”

Ms. Bessarab suggests you also have the senior tech shadow the new tech, once the practice deems he or she is ready, to ensure an accurate patient-medical history.

6. Have senior staff review the chart

To ensure accuracy, have a senior tech or, if possible, the ophthalmologist confirm all the necessary bases have been covered, explains Ms. Ledford.

“One of the things that helped me most when I was first starting out was that the doctor I worked for would sit with me at the end of each day and go over every chart of every patient I had taken a history of,” she says. “This was tremendously helpful in enabling me to avoid future mistakes. I realize this may not be feasible with today’s health-care environment, as doctors are more busy than they’ve ever been, so I’d recommend assigning a senior tech to a new tech to do this daily until he or she feels the new tech is ready to go it alone.”

Make the investment

Usually, you get what you pay for, but you also get what you invest in, Ms. Ledford says, which includes staff education. “If you take the time to properly train a novice tech, patients will be pleased with their care, ophthalmologists will receive their due reimbursement, and practices will be protected from chart audits,” she says. “The bottom line is that the practice will thrive.” OP