Ординатура / Офтальмология / Английские материалы / Clinical Skills for The Ophthalmic Examination Basic Procedure 2nd edition_DuBois_2005

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The Patient

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Patients seeking medical treatment may be fearful or anxious about their office visit. The oph-

thalmic or optometric assistant is usually the patient’s first contact in the clinical setting; there-

fore, he or she should try to establish a rapport with the patient. A positive first impression will

set the tone for the whole visit. This includes minimizing the patient’s wait time as much as pos-

sible.

It is of greatest importance that every patient be treated with respect and kindness. For exam-

ple, adults should not be addressed by their first names unless they request it. It is helpful to

remember that each patient is not just a professional client but a person who represents our most

important source of job satisfaction. The eyecare professional should treat each patient as if he or

she were a special visitor: putting him or her at ease, explaining procedures, giving clear instruc-

tions, empathizing, and inspiring confidence.

Every patient exam requires some preparation, attention to detail, and attention to the patient.

Some patients require more intensive professional and personal attention than others. Regardless

of a patient’s personal status (whether physical, emotional, or social), every person deserves

respectful, caring treatment. There is no typical patient; each patient brings unique problems and

needs to the visit and must be treated as an individual. In addition to technical skills and knowl-

edge, the assistant must bring compassion to the exam. Some special problems include accom-

modating patients who are 1) elderly; 2) visually, mentally, or physically impaired; 3) non-Eng-

lish speaking; 4) illiterate; or 5) very young.

The assistant should remember to help elderly patients who have trouble with mobility and

allow a reasonable amount of time to listen to the patient’s medical complaint. The assistant needs

to be attentive and patient during the examination without sacrificing efficiency. For example, a

casual external examination of the patient can be done while the patient describes the problem.

Helping the visually impaired can sometimes be frustrating. Never assume that the patient

wants or needs assistance. Simply ask the patient if he or she would like help. This shows respect

for the person’s ability to care for himor herself. However, once a need for help is established,

there are a few things the eyecare professional can do to allow the patient to feel confident while

maneuvering through the office. First, make sure obstacles have been moved out of the way and

that other office personnel are aware of the need for a clear path. When walking, the patient

should grasp the leader’s bent arm at the elbow. The leader should hold his or her own upper arm

against the body, thereby holding the patient’s fingers or hand between the body and arm so that

the patient is walking slightly behind and can feel the leader’s body as it changes direction. The

leader should never “tow” the patient by the hand; the patient will not feel confident that he or

she will not run into walls or door jambs. (Try both ways with a friend whose eyes are closed and

notice the difference in control of the “patient.”) Once the patient is ready to be seated, turn him

or her so that the backs of the legs are against the seat of the chair and place the patient’s hands

on the arms of the chair. During the exam, the assistant should guide the patient’s head or chin

onto the chin rest, being careful to inform the patient before making physical contact.

Mentally and physically impaired patients should be assisted as necessary. A mentally

impaired patient will almost always be accompanied by a caretaker. The caretaker should stay

with the patient at all times to help with the history and assist in completing the ocular exam. A

mentally impaired person should never be forced to cooperate, because this may cause anxiety

and agitation, preventing the completion of the exam. If it becomes impossible to continue the

exam, the assistant can inform the doctor and allow the patient to calm down in another (non-

exam) room. A note can be made in the patient’s chart that he or she was noncompliant.

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Physically impaired patients may require help maneuvering into the exam room and then into

the chair. When a patient is in a wheelchair, it should be rolled close to the exam chair, and the

brakes on each wheel should be set before the patient begins the transfer. The eyecare profes-

sional must be careful not to injure himor herself while assisting the patient and should ask for

help from other office personnel or those accompanying the patient. Again, the patient can deter-

mine how much assistance is needed. It is often useful to have the doctor come to the patient

rather than having to move the patient again.

Language barriers are often difficult to overcome during an ocular exam because so much

depends on the patient’s responses. At the time the appointment is made, if the patient does not

speak English, he or she should be instructed to bring someone who can translate. This is also

true for hearing impaired patients who use sign language. If no translator is available, the histo-

ry will be fragmented, and instructions to the patient probably will not be understood. However,

the patient can still be taught the “Tumbling E” test for acuity, and most other tests do not require

a response (ie, are not subjective). Illiterate patients can also be tested this way.

Infants and young children present a special challenge because they are often shy or afraid

and may be reluctant or unable to verbally communicate. While questioning parents, the profes-

sional should not ignore the child. Infants will respond to the examiner’s smile and touch. Ask

parents of infants returning to the office to postpone feeding the child and to bring a bottle to the

visit; a hungry baby taking his or her bottle will not be so disturbed by the exam. Younger chil-

dren can be gently questioned during the conversation with their parents; they will feel less threat-

ened if they are made part of the process. Older children and teenagers should be treated with the

same respect as adults, but a more casual attitude may help these patients feel more comfortable.

In addition to good communication skills, the eyecare professional should be attentive to the

patient’s comfort, expectations, and especially to the patient’s right to privacy. A happy, compli-

ant patient is one who is made to feel that he or she is a partner in the medical team.

Confidentiality

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One of the most important aspects of the interaction between the patient and any health care

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worker is the issue of privacy. The very nature of providing good health care requires that the

provider know personal medical and social information about the patient. This information is

considered strictly confidential and may not be divulged by anyone with privileged access to it

without the patient’s consent. The health care worker must treat all patient information with equal

respect for privacy; the patient is the only person who can decide which information might be

damaging or embarrassing. In addition to not discussing privileged information outside the office,

the health care worker must also be careful not to talk about a patient in the office hallways, where

other patients might overhear the conversation.

The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 to

ensure the continuity of a person's health insurance coverage and to protect a person's health

information. The latter goal has become the primary focus of HIPAA, and medical providers must

now obtain a patient's consent for disclosure of protected health information (PHI) that is not for

the express purpose of claims payment or continued care or treatment.

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