OSC Test Questions & Answers

OSC Test Questions & Answers 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