OPHTHALMIC SCRIBE CERTIFICATION OSC EXAM
QUESTIONS COMPLETE AND 100% VERIFIED ANSWERS
AND DETAILED EXPLANATIONS
QUESTION 1
What is the primary function of a medical scribe?
A) Perform eye examinations independently
B) Create the medical note (documentation)
C) Diagnose eye diseases
D) Prescribe medications for eye conditions
Correct Answer: B
Explanation: The primary function of a medical scribe is to create the medical
note (documentation) in real-time as the physician evaluates the patient. Scribes
do not perform examinations, diagnose, or prescribe; they document the
physician's findings and patient history to improve efficiency and accuracy.
QUESTION 2
What is the preferred format for the creation of the medical note?
A) PQRST (Provocation, Quality, Region, Severity, Timing)
B) Subjective, Objective, Assessment, Plan (SOAP)
C) CC, HPI, ROS, PE
D) OPQRST and PMHx
Correct Answer: B
Explanation: The SOAP (Subjective, Objective, Assessment, Plan) format is the
standard for medical documentation. Subjective includes patient-reported
information (chief complaint, history of present illness, review of systems).
,Objective includes measurable findings (vital signs, physical exam, lab/imaging
results). Assessment is the diagnosis or differential diagnosis. Plan is the
treatment plan.
QUESTION 3
Present time patient details are summarized by using which format?
A) SOAP
B) OPQRST (Onset, Provocation, Quality, Region/Radiation, Severity, Time)
C) CC and HPI
D) ROS and PMHx
Correct Answer: B
Explanation: OPQRST is used to characterize the history of present illness (HPI):
Onset (when did it start?), Provocation/Palliation (what makes it better or
worse?), Quality (what does it feel like?), Region/Radiation (where is it and does it
spread?), Severity (0-10 scale), Time (duration, frequency, constant vs
intermittent).
QUESTION 4
All Current Procedural Terminology (CPT) codes must be justified by what
appropriate coding mechanism?
A) SNOMED CT
B) International Classification of Disease (ICD) codes
C) LOINC
D) DRG codes
Correct Answer: B
Explanation: CPT codes (procedure codes) must be supported by ICD
(International Classification of Diseases) diagnosis codes that justify medical
necessity for the service performed. Insurance payers require that the ICD code
matches the CPT code for reimbursement. ICD-10-CM is the current version used
in the US.
QUESTION 5
What patient history is outlined in the PMHx?
,A) Family history of eye diseases
B) Medical history (past medical history)
C) Social history (smoking, alcohol)
D) Surgical history only
Correct Answer: B
Explanation: PMHx (Past Medical History) includes the patient's prior medical
conditions, hospitalizations, surgeries, illnesses, and significant health events. It
may also include medications, allergies, immunizations, and health maintenance.
This is distinct from Family History (FHx) and Social History (SHx).
QUESTION 6
What scribing includes blood pressure, heart rate, and respiratory rate?
A) Review of systems
B) Physical examination
C) Vital signs
D) History of present illness
Correct Answer: C
Explanation: Vital signs include blood pressure (BP), heart rate/pulse (HR),
respiratory rate (RR), temperature (T), oxygen saturation (SpO2), and sometimes
pain score. They are objective measurements of basic body functions and are
typically recorded in the Objective section of SOAP.
QUESTION 7
The chief complaint (CC), history of present illness (HPI), and review of systems
(ROS) are listed in what category of the medical note?
A) Objective
B) Assessment
C) Subjective
D) Plan
Correct Answer: C
Explanation: In the SOAP note, the Subjective section includes information
reported by the patient: Chief Complaint (CC) - reason for visit in patient's own
, words, History of Present Illness (HPI) - detailed story of the CC, Review of Systems
(ROS) - systematic questioning about symptoms in each body system, and Past
Medical/Family/Social History (PMHx/FHx/SHx).
QUESTION 8
The physical examination (PE), imaging, and laboratory results are listed in what
category of the medical note?
A) Subjective
B) Objective (O)
C) Assessment
D) Plan
Correct Answer: B
Explanation: The Objective section of SOAP contains measurable, observable data
obtained by the examiner: physical examination findings (PE), vital signs,
laboratory results, imaging results (X-ray, CT, MRI, ultrasound), and other
diagnostic test results.
QUESTION 9
Patient allergies and medications are listed under what category in the medical
note?
A) Objective
B) Assessment
C) Subjective (usually in PMHx or medications/allergies section)
D) Plan
Correct Answer: C
Explanation: Allergies and medications are patient-reported information,
therefore they belong in the Subjective section (typically within the Past Medical
History or a dedicated medications/allergies section). They are not objective
findings (cannot be measured) and are not part of Assessment or Plan.
QUESTION 10
Where does a scribe record the patient's comments regarding vision problems?
A) Physical examination
QUESTIONS COMPLETE AND 100% VERIFIED ANSWERS
AND DETAILED EXPLANATIONS
QUESTION 1
What is the primary function of a medical scribe?
A) Perform eye examinations independently
B) Create the medical note (documentation)
C) Diagnose eye diseases
D) Prescribe medications for eye conditions
Correct Answer: B
Explanation: The primary function of a medical scribe is to create the medical
note (documentation) in real-time as the physician evaluates the patient. Scribes
do not perform examinations, diagnose, or prescribe; they document the
physician's findings and patient history to improve efficiency and accuracy.
QUESTION 2
What is the preferred format for the creation of the medical note?
A) PQRST (Provocation, Quality, Region, Severity, Timing)
B) Subjective, Objective, Assessment, Plan (SOAP)
C) CC, HPI, ROS, PE
D) OPQRST and PMHx
Correct Answer: B
Explanation: The SOAP (Subjective, Objective, Assessment, Plan) format is the
standard for medical documentation. Subjective includes patient-reported
information (chief complaint, history of present illness, review of systems).
,Objective includes measurable findings (vital signs, physical exam, lab/imaging
results). Assessment is the diagnosis or differential diagnosis. Plan is the
treatment plan.
QUESTION 3
Present time patient details are summarized by using which format?
A) SOAP
B) OPQRST (Onset, Provocation, Quality, Region/Radiation, Severity, Time)
C) CC and HPI
D) ROS and PMHx
Correct Answer: B
Explanation: OPQRST is used to characterize the history of present illness (HPI):
Onset (when did it start?), Provocation/Palliation (what makes it better or
worse?), Quality (what does it feel like?), Region/Radiation (where is it and does it
spread?), Severity (0-10 scale), Time (duration, frequency, constant vs
intermittent).
QUESTION 4
All Current Procedural Terminology (CPT) codes must be justified by what
appropriate coding mechanism?
A) SNOMED CT
B) International Classification of Disease (ICD) codes
C) LOINC
D) DRG codes
Correct Answer: B
Explanation: CPT codes (procedure codes) must be supported by ICD
(International Classification of Diseases) diagnosis codes that justify medical
necessity for the service performed. Insurance payers require that the ICD code
matches the CPT code for reimbursement. ICD-10-CM is the current version used
in the US.
QUESTION 5
What patient history is outlined in the PMHx?
,A) Family history of eye diseases
B) Medical history (past medical history)
C) Social history (smoking, alcohol)
D) Surgical history only
Correct Answer: B
Explanation: PMHx (Past Medical History) includes the patient's prior medical
conditions, hospitalizations, surgeries, illnesses, and significant health events. It
may also include medications, allergies, immunizations, and health maintenance.
This is distinct from Family History (FHx) and Social History (SHx).
QUESTION 6
What scribing includes blood pressure, heart rate, and respiratory rate?
A) Review of systems
B) Physical examination
C) Vital signs
D) History of present illness
Correct Answer: C
Explanation: Vital signs include blood pressure (BP), heart rate/pulse (HR),
respiratory rate (RR), temperature (T), oxygen saturation (SpO2), and sometimes
pain score. They are objective measurements of basic body functions and are
typically recorded in the Objective section of SOAP.
QUESTION 7
The chief complaint (CC), history of present illness (HPI), and review of systems
(ROS) are listed in what category of the medical note?
A) Objective
B) Assessment
C) Subjective
D) Plan
Correct Answer: C
Explanation: In the SOAP note, the Subjective section includes information
reported by the patient: Chief Complaint (CC) - reason for visit in patient's own
, words, History of Present Illness (HPI) - detailed story of the CC, Review of Systems
(ROS) - systematic questioning about symptoms in each body system, and Past
Medical/Family/Social History (PMHx/FHx/SHx).
QUESTION 8
The physical examination (PE), imaging, and laboratory results are listed in what
category of the medical note?
A) Subjective
B) Objective (O)
C) Assessment
D) Plan
Correct Answer: B
Explanation: The Objective section of SOAP contains measurable, observable data
obtained by the examiner: physical examination findings (PE), vital signs,
laboratory results, imaging results (X-ray, CT, MRI, ultrasound), and other
diagnostic test results.
QUESTION 9
Patient allergies and medications are listed under what category in the medical
note?
A) Objective
B) Assessment
C) Subjective (usually in PMHx or medications/allergies section)
D) Plan
Correct Answer: C
Explanation: Allergies and medications are patient-reported information,
therefore they belong in the Subjective section (typically within the Past Medical
History or a dedicated medications/allergies section). They are not objective
findings (cannot be measured) and are not part of Assessment or Plan.
QUESTION 10
Where does a scribe record the patient's comments regarding vision problems?
A) Physical examination
