ocular infections
Setting the Record Straight on Ocular Infections
The symptoms of ocular infections are often mistaken for other conditions. That's why it's so important to perfect your record taking.
BY ROBERT B. DIMARTINO, O.D., M.S., F.A.A.O., & LILLIAN WANG, O.D., Berkeley, Calif.

Would your patient records stand up to the scrutiny of outside eyes (e.g., judges, lawyers, expert witnesses)? Do those pertaining to ocular infection follow generally accepted clinical guidelines? Over the years of our clinical practice, we know it's easy to fall victim to less-than-satisfactory charting habits. But what's the harm?

The painful truth

Carefully and thoughtfully developed guidelines are integral in obtaining a complete patient history and minimizing the risk of reaching a misdiagnosis. The patient history is just one part of complete record keeping that we all must adhere to. Fortunately, our basic science prerequisite coursework and optometry school classes prepared us to become grade-A record keepers.

In preparation for our careers in optometry, we studied the sciences (biology, chemistry and physics), which provided a foundation in basic science that our optometry training built upon. It may not seem entirely obvious, but there's good reason for having laboratory courses. One of these reasons is that it was in these labs that we began our training for keeping patient records.

Here we learned to record observations and data on the fly, and would allow meaningful reference later for our write up of the experiment. Our optometric training helped to further develop this essential skill. Now, instead of recording the amount of a reagent necessary for a chemical reaction, or the angle of deflection of a beam, we're recording patient complaints and findings from which we draw conclusions and form our treatment plans.

Let's review good charting techniques and clinical thought processes to ensure that our records will meet the scrutiny of unwelcomed eyes or an audit.

You know the routine

Conjunctivitis is a common complaint that we often encounter in our offices. To properly diagnose conjunctivitis, you should conduct a thorough history of present illness (HPI) before examining the patient. You may easily identify the common garden variety of bacterial or viral conjunctivitis.

Because these causes of conjunctivitis are what we most frequently encounter, you can keep the case history into the pink eye brief. We want to bypass the talking and examine the eye to alleviate the discomfort that the patient is experiencing. This is a potential huge error on our part. What if the pink eye isn't the result of the common bacteria or virus? What if a fungal infection caused the pink eye? What if the pink eye is the early stages of epidemic keratoconjunctivitis (EKC)? By properly and thoroughly conducting a complete HPI, we could head off a more serious misdiagnosis.

Getting things in order

Clinical thought process and patient charting take the same general form and consist of four parts:

1. Subjective (history or patient interview)

2. Objective (findings or observations)

3. Assessment (impressions or diagnosis)

4. Plan.

The order of these components is specific. For example, it would make no sense to develop a treatment plan for a patient before you arrive at a diagnosis. But in addition to being logical, the order guides us in the clinical thought process. A well-designed history will tailor the direction of our objective examination.

First things first

The chief (or presenting) complaint is what drives the subjective portion of patient charting. Write this complaint in the chart as an incomplete phrase (e.g., "eye hurts") and in the patient's own words. These same words should mark the end of the subjective portion of your exam. However, this time use the patient's words in a question to confirm your understanding of the central reason the patient has sought care.

You could state this formally, "Are you here today because your eye hurts?" or less formally, "Your eye hurts?" Either way validates your understanding of the patient's chief complaint and reassures him that you're on track with what's most important to him.

We've reviewed patient charts in malpractice cases where the central issue was a disagreement between the patient and provider about the chief reason why the patient presented for care. To eliminate this type of criticism of your care and of your record keeping, establish a way to indicate that you confirmed the patient's chief complaint. Perhaps use the letter "C" with a circle around it at the end of the chief complaint to indicate that you confirmed the patient's central reason for seeking your care.

The goal of good charting is to ensure that you're thorough when investigating your patient's complaints. Regardless, if you note the chief complaint on your pre-printed intake forms, or you elicit it from the patient once he's in your examination chair, then it's essential that a complete investigation ensue. Of course, sometimes a complaint is ordinary and you can simply note that. When we don't completely investigate these complaints we're vulnerable to criticism that the patient history that we recorded in the chart is incomplete.

What happens between the patient's statement regarding his motivation for seeking care and your re-statement of the chief complaint is a critical piece in recording a thorough history. The better you are at this process, the more focused your exam. The formal terminology for this is the HPI. As we've already mentioned, the HPI clarifies the chief complaint and directs your exam. It also communicates to the patient, and to subsequent reviewers of your records, that your attention was drawn to the patient's chief complaint(s).

Take a look at "Red Eye #1" and "Red Eye #2" for a few examples of patients presenting with red eyes. In "Red Eye #2," the HPI consisted of the differential diagnosis -- a grave mistake that leads to a total breakdown of the clinical thought process. "Red Eye #3" and "Red Eye #4" provide additional examples of complete histories.

Through a more complete history, we learned that this virus has infected multiple individuals and that it's contagious. This would heighten our suspicion that a likely diagnosis is epidemic keratoconjunctivitis. This diagnosis would alter our examination procedures, perhaps prompting us to use disposable gloves and ensure the examination room and its contents are wiped down and sterilized.

Take a thorough history

An example of a thorough HPI for red eye includes the following questions:

• When did the red eye begin? (Onset)
• Was there any discharge? (Associated signs and symptoms)
• Has anyone else in the family had red eye?
• Were there any incidents (e.g., plant material in the eye) that preceded the red eye? (Associated signs and symptoms)
• Was there any pain or photophobia present? (Associated signs and symptoms)
• Is this the first time that your eye has been red or have you experienced other episodes in the past?

In "Red Eye #3," our notation of the laterality and prior history of associated findings is critical in directing our exam and reaching the appropriate diagnosis of herpes simplex keratitis/ conjunctivitis. Reaching the wrong diagnosis in this case might result in a treatment plan with a steriod or steroid antibiotic and lead to therapeutic disaster.

In "Red Eye #4," the complete history points the examination and begins to limit possible diagnoses. If we hadn't asked the last two questions in the HPI ("Is this the first time you've had a red eye" and "Have you had any changes in your personal life over the last few three to four months?"), then the history wouldn't be as definitive. We might have been lured into making a diagnosis of bacterial conjunctivitis. Because of our final two questions, we've narrowed the etiologies of the red eye(s). There is a stronger likelihood that the diagnosis is either from the sexually transmitted disease chlamydia or it could be a self-inflicted condition (Munchhausen syndrome). Regardless, it would be inappropriate to treat this patient with only topical agents and without further evaluation.

Keep your records straight

Whether a patient presents with a complaint suggestive of ocular infection or he simply presents for routine care, be aware of all possibilities and be meticulous in your record taking. Careless record keeping, including incomplete patient history, can come back to haunt you -- especially when you're dealing with an undiagnosed and/or untreated ocular infection. You know what to do now, so put that knowledge to use. Do the best for your patients and in the process, know that your records would withstand outside scrutiny.