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What is the primary function of a Medical Scribe? ✔Correct Answer-Assist with patient exam
What is a preferred format for the creation of a Medical Note ✔Correct Answer-Subjective,
Objective, Assessment, Plan (SOAP)
"Present Time" patient details are summarized by using what format? ✔Correct Answer-
OPQRST
All Current Procedural Terminology (CPT) code must be justified by what appropriate coding
mechanism? ✔Correct Answer-International Classification of Disease (ICD)
What patient history is outlined in the PMHx? ✔Correct Answer-Medical history
What scribing category includes: Blood Pressure (BP), Heart rate (HR), & Respiratory Rate (RR)?
✔Correct Answer-Vital Signs (VS)
The Chief Complaint (CC), History of Present Illness (HPI) & Review of Symptoms (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
Patient allergies and medications are listed under what category in the Medical Note?
✔Correct Answer-Subjective
Where does a scribe record the patient's comments regarding vision problems? ✔Correct
Answer-Chief Complaint (CC)
Which of the following statements is TRUE regarding taking an ocular history? ✔Correct
Answer-The patient's systemic drug therapy may produce ocular symptoms
All of the following are important to document in the history of an ocular injury, EXCEPT
✔Correct Answer-The presence of others when injury occured
In obtaining the past medical history for a pt about to have eye surgery, which of the following is
MOST important? ✔Correct Answer-Allergies to medications
, When taking a pt's history, it is important to inquire about hypertensions 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
What is the abbreviation for antibotics? ✔Correct Answer-ABX
What is the abbreviation for discharge? ✔Correct Answer-D/C
Giant Papillary Conjunctivitis is noted on the pt's chart as.. ✔Correct Answer-GPC
How is fin needle aspiration noted in the pt's chart? ✔Correct Answer-FNA
How is the Goldmann visual field test noted in a pt's chart? ✔Correct Answer-GVF
What is the acronym for axial eye length ✔Correct Answer-AL
the acronym "BC" stands for? ✔Correct Answer-Base curve
What does "BI" indicate on a spectacle prescription? ✔Correct Answer-Base-in prism
What does "BUT" stand for on a pt's chart regarding tear film? ✔Correct Answer-Breakup
time
The acronym "CN" stands for ✔Correct Answer-Cranial nerve
The acronym "CV" stands for ✔Correct Answer-Color vision
What does the notation "FTP" indicate on a chart of a child with strabismus ✔Correct Answer-
Full time patch
What does the notation "DR" indicate regarding a pt's condition? ✔Correct Answer-Diabetic
retinopathy
What is the acronym for extraocular muscles? ✔Correct Answer-EOM
What is an LVA ✔Correct Answer-Low visual acuity
RAPD is the acronym for what condition? ✔Correct Answer-Relative afferent papillary defect
What would the acronym "NLP" indicate on a pt's chart? ✔Correct Answer-No light
perception