The lecture covers the essentials of history taking both for a comprehensive and a problem-focused exam. Each component of the patient case history is covered including demographic data, chief complaint, history presenting illness, ocular history, review of systems, and family and social history. The importance of documentation for medico-legal aspects will be discussed as well as the difference between paper and electronic documentation. Case examples and practice pearls will also be presented.
- 1. Conduct a thorough basic case history using appropriate questioning techniques
- 2. Identify and apply medico-legal aspects of documentation
- 3. Demonstrate differences between paper and electronic documentation
- 4. Relate basic requirements of history taking according to federal/insurance regulations
- 5. Understand importance of each component of the case history as they pertain to the process of differential diagnosis