Answers Guaranteed Success OSC test Questions and
what is the primary function of a medical scribe?
create the medical note
what is the preferred format for the creation of the medical note?
subjective, pbjective, assessment, plan (soap)
"present time" pt details are summarized by using what format
OPQRST
all current procedural terminology (CPT) codes must be justified by what
appropiate coding mechanisms
international classification of disease (ICD)
what patient history is outlined in the PMHx
medical history
what scribing include: blood pressure, heart rate, and respiratory rate
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?
subjective
the physical examination (PE) imaging and Laboratory results are listed in what
category of the medical note?
objective
pt allergies and medications are listed under what category in the medical note?
subjective
where does a scribe record the pt's comments regarding vision problems?
chief complaint (CC)
which of the following statements is true regarding taking ocular history?
the pt's systematic drug therapy may produce ocular systems
name three important things to document in the history of an ocular injury
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?
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...
administer dilating drops
what is the most important entry a scribe can make in the pt chart?
what the physician finds in the course of the exam
abbreviation for antibiotics?
ABX
abbreviation for discharge?
D/C
giant papillary conjuctivitis is noted on the pt's chart as
GPC
, how is a fine needle aspiration noted in the pts chart/?
FNA
acronym for axial length?
AL
acronym for BC
base curve
what does BI indicate on a spectacle prescription?
base-in prism
what deos BUT stand for on a pt's chart regarding tear film?
break up time
acronym for CN
cranial nerve
acronym for CV
color vision
what does the notation for FTP indicate on a chart of a child with strabismus?
full time patch
what does the notation DR indicate regarding a pts condition?
diabetic retinopathy
acronym for extraocular muscles
EOM
what is a LVA?
low vision aid
acronym for RAPD?
relative afferent papillary defect
acronym for NLP?
no light perception
what is HPI?
history of pt illness
how does a scribe indicate a pts pupils are equal, round and reactive to light?
PERRL
acronym fro ADR?
adverse drug reaction
acronym for ADR
altered mental status
acronym for a plastic lens that may be surgically implanted to replace the eye's
natural lense?
IOL
term for clear gel filling inside the eye?
vitreous
what structure is comprised of the capsule, cortex, and nucleus?
crystalline lens
what landmark is located at the front edge of hte retina and has a tooth-like
apperance
ora serrata
name of the area inside the eye between the iris and the inner most corneal
surface?
what is the primary function of a medical scribe?
create the medical note
what is the preferred format for the creation of the medical note?
subjective, pbjective, assessment, plan (soap)
"present time" pt details are summarized by using what format
OPQRST
all current procedural terminology (CPT) codes must be justified by what
appropiate coding mechanisms
international classification of disease (ICD)
what patient history is outlined in the PMHx
medical history
what scribing include: blood pressure, heart rate, and respiratory rate
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?
subjective
the physical examination (PE) imaging and Laboratory results are listed in what
category of the medical note?
objective
pt allergies and medications are listed under what category in the medical note?
subjective
where does a scribe record the pt's comments regarding vision problems?
chief complaint (CC)
which of the following statements is true regarding taking ocular history?
the pt's systematic drug therapy may produce ocular systems
name three important things to document in the history of an ocular injury
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?
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...
administer dilating drops
what is the most important entry a scribe can make in the pt chart?
what the physician finds in the course of the exam
abbreviation for antibiotics?
ABX
abbreviation for discharge?
D/C
giant papillary conjuctivitis is noted on the pt's chart as
GPC
, how is a fine needle aspiration noted in the pts chart/?
FNA
acronym for axial length?
AL
acronym for BC
base curve
what does BI indicate on a spectacle prescription?
base-in prism
what deos BUT stand for on a pt's chart regarding tear film?
break up time
acronym for CN
cranial nerve
acronym for CV
color vision
what does the notation for FTP indicate on a chart of a child with strabismus?
full time patch
what does the notation DR indicate regarding a pts condition?
diabetic retinopathy
acronym for extraocular muscles
EOM
what is a LVA?
low vision aid
acronym for RAPD?
relative afferent papillary defect
acronym for NLP?
no light perception
what is HPI?
history of pt illness
how does a scribe indicate a pts pupils are equal, round and reactive to light?
PERRL
acronym fro ADR?
adverse drug reaction
acronym for ADR
altered mental status
acronym for a plastic lens that may be surgically implanted to replace the eye's
natural lense?
IOL
term for clear gel filling inside the eye?
vitreous
what structure is comprised of the capsule, cortex, and nucleus?
crystalline lens
what landmark is located at the front edge of hte retina and has a tooth-like
apperance
ora serrata
name of the area inside the eye between the iris and the inner most corneal
surface?
