OPHTHALMIC SCRIBE CERTIFICATION EXAM
COMPLETE 228 QUESTIONS & 100%
VERIFIED ANSWERS WITH DETAILED
EXPLANATIONS
1. what is the primary function of a medical scribe?
Correct Answer: CREATE the medical note
Explanation: The scribe documents the entire patient encounter in
real-time, allowing the physician to focus on clinical care rather
than data entry.
2. what is the preferred format for the creation of the medical note?
Correct Answer: Subjective, Objective, Assessment, Plan (SOAP)
Explanation: SOAP is the universal standard organizing patient
information into four logical sections: patient-reported symptoms,
measurable findings, diagnosis, and treatment plan.
3. "present time" pt details are summarized by using what format?
Correct Answer: OPQRST
Explanation: OPQRST (Onset, Provocation/Palliation, Quality,
Region/Radiation, Severity, Time) is a mnemonic for capturing
detailed history of present illness.
4. all current procedural terminology (CPT) codes must be justified
by what appropriate coding mechanisms?
Correct Answer: International Classification of Disease (ICD)
, Explanation: CPT codes describe procedures performed; ICD codes
describe diagnoses. ICD codes must support medical necessity for
the billed CPT codes.
5. what patient history is outlined in the PMHx?
Correct Answer: medical history
Explanation: PMHx (Past Medical History) includes chronic
conditions, prior surgeries, hospitalizations, and significant past
illnesses.
6. what does scribing include: blood pressure, heart rate, and
respiratory rate?
Correct Answer: vital signs
Explanation: Vital signs are objective baseline measurements of
body function, including BP, HR, RR, temperature, and SpO2.
7. the chief complaint (CC), history of present illness (HPI), and
review of systems (ROS) are listed in what category of the medical
note?
Correct Answer: subjective
Explanation: These sections contain information reported by the
patient, not yet measured or observed by the physician.
8. the physical examination (PE), imaging, and laboratory results are
listed in what category of the medical note?
Correct Answer: objective
Explanation: The Objective section contains measurable, verifiable
data including exam findings, imaging, and lab results.
9. pt allergies and medications are listed under what category in the
medical note?
Correct Answer: subjective
, Explanation: Allergies and medications are patient-reported
information, typically obtained during history taking, placing them
in the Subjective section.
10. where does a scribe record the pt's comments regarding
vision problems?
Correct Answer: chief complaint (CC)
Explanation: The chief complaint is the patient's own words
describing the reason for the visit, including vision problems.
11. which of the following statements is true regarding taking
ocular history?
A) The patient's systemic drug therapy never produces ocular
symptoms
B) The patient's systemic drug therapy may produce ocular
symptoms
C) Only topical eye medications produce ocular symptoms
D) Ocular history is not affected by systemic diseases
Correct Answer: B) The patient's systemic drug therapy may
produce ocular symptoms
Explanation: Many systemic medications (hydroxychloroquine,
amiodarone, tamoxifen, ethambutol, corticosteroids) have well-
known ocular side effects including retinopathy, corneal deposits,
optic neuropathy, and glaucoma.
12. 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
, Explanation: Mechanism, timing, and prior treatment are critical
for assessing severity, risk of infection, and need for further
intervention.
13. in obtaining the past medical history for a patient about to
have eye surgery, what is MOST important?
A) Previous surgical history
B) Family history of eye disease
C) Allergies to medications
D) Social history including smoking
Correct Answer: C) Allergies to medications
Explanation: Perioperative allergic reactions (to antibiotics,
anesthetics, iodine-based antiseptics, or latex) can cause
anaphylaxis, a life-threatening emergency.
14. when taking the patient's history, it is important to inquire
about hypertension and anti-hypertensive medications because
they may be a factor in determining whether to...
A) Perform a visual field test
B) Administer dilating drops
C) Measure intraocular pressure
D) Check color vision
Correct Answer: B) Administer dilating drops
Explanation: Mydriatic drops (especially phenylephrine) can cause
hypertensive crisis in patients with uncontrolled hypertension.
Alpha-blockers (like tamsulosin) cause intraoperative floppy iris
syndrome (IFIS) during cataract surgery.
15. what is the most important entry a scribe can make in the pt
chart?
COMPLETE 228 QUESTIONS & 100%
VERIFIED ANSWERS WITH DETAILED
EXPLANATIONS
1. what is the primary function of a medical scribe?
Correct Answer: CREATE the medical note
Explanation: The scribe documents the entire patient encounter in
real-time, allowing the physician to focus on clinical care rather
than data entry.
2. what is the preferred format for the creation of the medical note?
Correct Answer: Subjective, Objective, Assessment, Plan (SOAP)
Explanation: SOAP is the universal standard organizing patient
information into four logical sections: patient-reported symptoms,
measurable findings, diagnosis, and treatment plan.
3. "present time" pt details are summarized by using what format?
Correct Answer: OPQRST
Explanation: OPQRST (Onset, Provocation/Palliation, Quality,
Region/Radiation, Severity, Time) is a mnemonic for capturing
detailed history of present illness.
4. all current procedural terminology (CPT) codes must be justified
by what appropriate coding mechanisms?
Correct Answer: International Classification of Disease (ICD)
, Explanation: CPT codes describe procedures performed; ICD codes
describe diagnoses. ICD codes must support medical necessity for
the billed CPT codes.
5. what patient history is outlined in the PMHx?
Correct Answer: medical history
Explanation: PMHx (Past Medical History) includes chronic
conditions, prior surgeries, hospitalizations, and significant past
illnesses.
6. what does scribing include: blood pressure, heart rate, and
respiratory rate?
Correct Answer: vital signs
Explanation: Vital signs are objective baseline measurements of
body function, including BP, HR, RR, temperature, and SpO2.
7. the chief complaint (CC), history of present illness (HPI), and
review of systems (ROS) are listed in what category of the medical
note?
Correct Answer: subjective
Explanation: These sections contain information reported by the
patient, not yet measured or observed by the physician.
8. the physical examination (PE), imaging, and laboratory results are
listed in what category of the medical note?
Correct Answer: objective
Explanation: The Objective section contains measurable, verifiable
data including exam findings, imaging, and lab results.
9. pt allergies and medications are listed under what category in the
medical note?
Correct Answer: subjective
, Explanation: Allergies and medications are patient-reported
information, typically obtained during history taking, placing them
in the Subjective section.
10. where does a scribe record the pt's comments regarding
vision problems?
Correct Answer: chief complaint (CC)
Explanation: The chief complaint is the patient's own words
describing the reason for the visit, including vision problems.
11. which of the following statements is true regarding taking
ocular history?
A) The patient's systemic drug therapy never produces ocular
symptoms
B) The patient's systemic drug therapy may produce ocular
symptoms
C) Only topical eye medications produce ocular symptoms
D) Ocular history is not affected by systemic diseases
Correct Answer: B) The patient's systemic drug therapy may
produce ocular symptoms
Explanation: Many systemic medications (hydroxychloroquine,
amiodarone, tamoxifen, ethambutol, corticosteroids) have well-
known ocular side effects including retinopathy, corneal deposits,
optic neuropathy, and glaucoma.
12. 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
, Explanation: Mechanism, timing, and prior treatment are critical
for assessing severity, risk of infection, and need for further
intervention.
13. in obtaining the past medical history for a patient about to
have eye surgery, what is MOST important?
A) Previous surgical history
B) Family history of eye disease
C) Allergies to medications
D) Social history including smoking
Correct Answer: C) Allergies to medications
Explanation: Perioperative allergic reactions (to antibiotics,
anesthetics, iodine-based antiseptics, or latex) can cause
anaphylaxis, a life-threatening emergency.
14. when taking the patient's history, it is important to inquire
about hypertension and anti-hypertensive medications because
they may be a factor in determining whether to...
A) Perform a visual field test
B) Administer dilating drops
C) Measure intraocular pressure
D) Check color vision
Correct Answer: B) Administer dilating drops
Explanation: Mydriatic drops (especially phenylephrine) can cause
hypertensive crisis in patients with uncontrolled hypertension.
Alpha-blockers (like tamsulosin) cause intraoperative floppy iris
syndrome (IFIS) during cataract surgery.
15. what is the most important entry a scribe can make in the pt
chart?
