Ophthalmic Scribe Certification OSC
Study Guide With Complete
Questions And Correct Answers
what is the primary function of a medical scribe? - Ans--create the medical
note
what is the preferred format for the creation of the medical note? - Ans--
subjective, objective, assessment, plan (soap)
"present time" pt details are summarized by using what format - Ans--
OPQRST
all current procedural terminology (CPT) codes must be justified by what
appropiate coding mechanisms - Ans--international classification of
disease (ICD)
what patient history is outlined in the PMHx - Ans--medical history
what scribing include: blood pressure, heart rate, and respiratory rate -
Ans--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? - Ans--
subjective
the physical examination (PE) imaging and Laboratory results are listed in
what category of the medical note? - Ans--objective
pt allergies and medications are listed under what category in the medical
note? - Ans--subjective
where does a scribe record the pt's comments regarding vision problems? -
Ans--chief complaint (CC)
, which of the following statements is true regarding taking ocular history? -
Ans--the pt's systematic drug therapy may produce ocular systems
name three important things to document in the history of an ocular injury -
Ans--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? - Ans--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... - Ans--administer dilating drops
what is the most important entry a scribe can make in the pt chart? - Ans--
what the physician finds in the course of the exam
abbreviation for antibiotics? - Ans--ABX
abbreviation for discharge? - Ans--D/C
giant papillary conjuctivitis is noted on the pt's chart as - Ans--GPC
how is a fine needle aspiration noted in the pts chart/? - Ans--FNA
acronym for axial length? - Ans--AL
acronym for BC - Ans--base curve
what does BI indicate on a spectacle prescription? - Ans--Base in prism
what does BUT stand for on a pt's chart regarding tear film? - Ans--break up
time
acronym for CN - Ans--cranial nerve
Study Guide With Complete
Questions And Correct Answers
what is the primary function of a medical scribe? - Ans--create the medical
note
what is the preferred format for the creation of the medical note? - Ans--
subjective, objective, assessment, plan (soap)
"present time" pt details are summarized by using what format - Ans--
OPQRST
all current procedural terminology (CPT) codes must be justified by what
appropiate coding mechanisms - Ans--international classification of
disease (ICD)
what patient history is outlined in the PMHx - Ans--medical history
what scribing include: blood pressure, heart rate, and respiratory rate -
Ans--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? - Ans--
subjective
the physical examination (PE) imaging and Laboratory results are listed in
what category of the medical note? - Ans--objective
pt allergies and medications are listed under what category in the medical
note? - Ans--subjective
where does a scribe record the pt's comments regarding vision problems? -
Ans--chief complaint (CC)
, which of the following statements is true regarding taking ocular history? -
Ans--the pt's systematic drug therapy may produce ocular systems
name three important things to document in the history of an ocular injury -
Ans--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? - Ans--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... - Ans--administer dilating drops
what is the most important entry a scribe can make in the pt chart? - Ans--
what the physician finds in the course of the exam
abbreviation for antibiotics? - Ans--ABX
abbreviation for discharge? - Ans--D/C
giant papillary conjuctivitis is noted on the pt's chart as - Ans--GPC
how is a fine needle aspiration noted in the pts chart/? - Ans--FNA
acronym for axial length? - Ans--AL
acronym for BC - Ans--base curve
what does BI indicate on a spectacle prescription? - Ans--Base in prism
what does BUT stand for on a pt's chart regarding tear film? - Ans--break up
time
acronym for CN - Ans--cranial nerve
