Actual Complete Exam |Already Graded A+
what is the primary function of a medical scribe? ✔Correct Answer-create the medical note
what is the preferred format for the creation of the medical note? ✔Correct Answer-
subjective, pbjective, assessment, plan (soap)
"present time" pt details are summarized by using what format ✔Correct Answer-OPQRST
all current procedural terminology (CPT) codes must be justified by what appropiate coding
mechanisms ✔Correct Answer-international classification of disease (ICD)
what patient history is outlined in the PMHx ✔Correct Answer-medical history
what scribing include: blood pressure, heart rate, and respiratory rate ✔Correct Answer-vital
signs
the chief complaint (CC) history of present illness (HPI) adn review of systems (ROS) are listed in
what category of the medical note? ✔Correct Answer-subjective
the physical examination (PE) imaging and Laboratory results are listed in what category of the
medical note? ✔Correct Answer-objective
pt allergies and medications are listed under what category in the medical note? ✔Correct
Answer-subjective
where does a scribe record the pt's comments regarding vision problems? ✔Correct Answer-
chief complaint (CC)
which of the following statements is true regarding taking ocular history? ✔Correct Answer-
the pt's systematic drug therapy may produce ocular systems
name three important things to document in the history of an ocular injury ✔Correct Answer-
1. how the injury occurred
2. the time the injury occurred
3. the treatment received since the injury occurred.
in obtaining the past medical history for a pt about to have eye sx, what is MOST important?
✔Correct Answer-allergies to medications
, when taking the pt's history, it is important to inquire about hypertension and anti-hypertensive
medications because they may be a factor in determining whether to... ✔Correct Answer-
administer dilating drops
what is the most important entry a scribe can make in the pt chart? ✔Correct Answer-what
the physician finds in the course of the exam
abbreviation for antibiotics? ✔Correct Answer-ABX
abbreviation for discharge? ✔Correct Answer-D/C
giant papillary conjuctivitis is noted on the pt's chart as ✔Correct Answer-GPC
how is a fine needle aspiration noted in the pts chart/? ✔Correct Answer-FNA
acronym for axial length? ✔Correct Answer-AL
acronym for BC ✔Correct Answer-base curve
what does BI indicate on a spectacle prescription? ✔Correct Answer-base-in prism
what deos BUT stand for on a pt's chart regarding tear film? ✔Correct Answer-break up time
acronym for CN ✔Correct Answer-cranial nerve
acronym for CV ✔Correct Answer-color vision
what does the notation for FTP indicate on a chart of a child with strabismus? ✔Correct
Answer-full time patch
what does the notation DR indicate regarding a pts condition? ✔Correct Answer-diabetic
retinopathy
acronym for extraocular muscles ✔Correct Answer-EOM
what is a LVA? ✔Correct Answer-low vision aid
acronym for RAPD? ✔Correct Answer-relative afferent papillary defect
acronym for NLP? ✔Correct Answer-no light perception
what is HPI? ✔Correct Answer-history of pt illness