CORRECT Answers
what is the primary function of a medical scribe? - CORRECT ANSWER-✔✔ create the
medical note
what is the preferred format for the creation of the medical note? - CORRECT ANSWER-
✔✔ subjective, pbjective, assessment, plan (soap)
"present time" pt details are summarized by using what format - CORRECT ANSWER-✔✔
OPQRST
all current procedural terminology (CPT) codes must be justified by what appropiate coding
mechanisms - CORRECT ANSWER-✔✔ international classification of disease (ICD)
what patient history is outlined in the PMHx - CORRECT ANSWER-✔✔ medical history
what scribing include: blood pressure, heart rate, and respiratory rate - CORRECT
ANSWER-✔✔ 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? - CORRECT ANSWER-✔✔ subjective
the physical examination (PE) imaging and Laboratory results are listed in what category of
the medical note? - CORRECT ANSWER-✔✔ objective
pt allergies and medications are listed under what category in the medical note? - CORRECT
ANSWER-✔✔ subjective
where does a scribe record the pt's comments regarding vision problems? - CORRECT
ANSWER-✔✔ chief complaint (CC)
, which of the following statements is true regarding taking ocular history? - CORRECT
ANSWER-✔✔ the pt's systematic drug therapy may produce ocular systems
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.
in obtaining the past medical history for a pt about to have eye sx, what is MOST important?
- CORRECT ANSWER-✔✔ 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... -
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
abbreviation for antibiotics? - CORRECT ANSWER-✔✔ ABX
abbreviation for discharge? - CORRECT ANSWER-✔✔ D/C
giant papillary conjuctivitis is noted on the pt's chart as - CORRECT ANSWER-✔✔ GPC
how is a fine needle aspiration noted in the pts chart/? - CORRECT ANSWER-✔✔ FNA
acronym for axial length? - CORRECT ANSWER-✔✔ AL
acronym for BC - CORRECT ANSWER-✔✔ base curve
what does BI indicate on a spectacle prescription? - CORRECT ANSWER-✔✔ base-in prism