Entering Complaints
Complaints are any ocular concerns, with descriptors, the patient would like addressed during their appointment. Complaints fall into one of two camps: Medical and Vision; and for every visit there will be at least one complaint that is considered the Chief Complaint. Here is an example of how to ask a patient if they have any complaints:
“Mr X, has there been anything out of the ordinary with your eyes going on recently? Any itching, redness, irritation, pain of any kind? Any new flashing lights or new floaters? Any overall change in vision at distance or at near?”
The inquiry begins with an open ended question that will allow the patient to voice specific concerns they had coming into the appointment. If the patient responds with no concerns, examples are offered of both medical (itching, redness, irritation, pain, flashing lights, floaters) and vision (overall change in vision at distance or near) complaints to help trigger recollection of concerns they may have forgotten about.
All complaints are entered into the patient record using the complaint history table which compiles a presenting problem along with at least four descriptors into a paragraph format. You can enter as many complaints as you need to. Here's a look at the presenting problem and descriptors including examples of how to fill them out.
Presenting problem: A sentence fragment describing the primary symptom/condition that stands out from any other accompanying symptoms (i.e. redness, pain, Myopia, Presbyopia)
Descriptors:
· Location: What is the site of the problem? Is it unilateral (one eye) or bilateral (both eyes)?
· Quality: What is the nature of the pain? Is it constant, acute, chronic, improved or worsening?
· Severity: Describe the symptom on a scale of 1 to 10, with 10 being the worst.
· Duration: How long has the problem been an issue?
· Timing: Is the problem worse in the morning or evening, or is it constant?
· Context: Is it associated with any activity? Did something happen prior to onset of the symptoms?
· Signs and symptoms: symptoms that accompany the primary symptom, blurred vision? Headache? Twitching? Excessive tearing?
· Relieving factors: What efforts has the patient made to improve the problem? Heat? Artificial tears? Other?
· Aggravating factors: Sunlight? Blinking?
· Negative: Pertinent symptoms the patient reports they do not have.
Where to find the Complaint History Table in Eyecare.
The highlighted area is where the complaints are entered. Each new entry is added using the three dot ellipsis in the upper left corner. This will add a new entry to the list. Previous complaints are visible and sorted by date with the most recent at the bottom.
This is the window that will open up when selecting to add a new complaint. In addition to the presenting problem, you will need to fill out at least four other descriptors such as location, severity, duration, timing, etc.
Chief Complaint and the difference between Medical and Vision Chief Complaints
Out of all the complaints the patient reports, one of them will be recorded as the Chief Complaint. The Chief Complaint is considered the primary reason for the appointment; this is determined first and foremost by the type of insurance being billed for the visit. Different types of insurances require different types of Chief Complaints. Vision insurances require the Chief Complaint to be a visual complaint which always has one of the patient’s refractive errors listed as the presenting problem (i.e. Myopia, Hyperopia, Presbyopia; any vision complaints such as “change in distance vision” should be entered under the signs/symptoms descriptor rather than having a separate complaint entry). Medical insurances require that the Chief Complaint be a medical complaint which can list anything other than a refractive error as the presenting problem. The above example of “pain” illustrates what a medical chief complaint might look like. Below would be an example of a vision Chief Complaint.
Note that with all vision Chief Complaints, the presenting problem begins with “monitor” followed by the refractive error. Four other descriptors are still filled in.
Again, what we enter as the patient’s Chief Complaint is dictated first and foremost by the type of insurance being billed for the visit. This means that if a patient comes in for a full exam with the intent to bill the exam to their vision insurance and during the complaint assessment they report no vision complaints per se but remark that they have been experiencing pain in their right eye for the past few days; pain could not be used for the Chief Complaint. The Chief Complaint would need to be one of their refractive errors as is illustrated by the vision Chief Complaint example above.
How do you distinguish the Chief Complaint from other complaints? You will note in the above examples there is a check box labeled “primary”. This will automatically be filled in for the first complaint entered at each visit, all subsequent entries will be be unchecked. If a patient shows up to their exam with medical complaints, but we are billing the exam to their vision insurance, you will fill out the initial complaint with their refractive error (this complaint will have the “primary” box checked, making it the Chief Complaint), and then add an additional medical complaint (with the “primary” box unchecked).
What if a patient has no complaints? If the visit is being billed to vision you will use their refractive error. If the visit is being billed to medical you can use any medical diagnosis in the plan (new or forwarded from a previous visit).
Introduction to chief complaints for intermediates
Intermediate appointments, just like exams, should always have a chief complaint entry. Chief complaints for intermediates fall into two sub categories which are detailed below.
Chief Complaints for Intermediate Appointments When Insurance is Billed
The Chief Complaint for intermediate appointments will always be the diagnosis that is the reason for the appointment. This means that for an IOP check, the Chief Complaint will be their glaucoma status (POAG-B, NAG, NAG-B, etc). For a follow-up, the Chief Complaint will be the diagnosis that the doctor is checking. For an I-Lux, the Chief Complaint would be their dry eye diagnosis.
This would be an example of what a Chief Complaint could look like for an IOP check.
Chief Complaints When No Insurance Is Billed
Lastly, there are intermediate appointments that are not billed to insurance (usually because the initial amount billed to insurance covers related follow up visits). The most common of these are contact lens checks (others include cl dispenses, rx checks). For these types of appointments the Chief Complaint will simply be the type of appointment along with any other descriptors that the doctor may wish entered. Please see the example below.
Note that because this appointment is not being billed to insurance, it bypasses the need to have four additional descriptors.
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