JCAHPO OSC Test – Questions With Complete Solutions
What is the primary function of a medical scribe? Right Ans - create the
medical note
What is the preferred format for the creation of the medical note? Right
Ans - subjective, pbjective, assessment, plan (soap)
"Present time" pt details are summarized by using what format Right Ans -
OPQRST
All current procedural terminology (CPT) codes must be justified by what
appropriate coding mechanisms Right Ans - international classification of
disease (ICD)
What patient history is outlined in the PMHx Right Ans - medical history
What scribing include: blood pressure, heart rate, and respiratory rate
Right 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? Right Ans -
subjective
The physical examination (PE) imaging and Laboratory results are listed in
what category of the medical note? Right Ans - objective
pt allergies and medications are listed under what category in the medical
note? Right Ans - subjective
Where does a scribe record the pt's comments regarding vision problems?
Right Ans - chief complaint (CC)
Which of the following statements is true regarding taking ocular history?
Right Ans - the pt's systematic drug therapy may produce ocular systems
Name three important things to document in the history of an ocular injury
Right 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? Right 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... Right Ans - administer dilating drops
what is the most important entry a scribe can make in the pt chart? Right
Ans - what the physician finds in the course of the exam
abbreviation for antibiotics? Right Ans - ABX
abbreviation for discharge? Right Ans - D/C
giant papillary conjuctivitis is noted on the pt's chart as Right Ans - GPC
how is a fine needle aspiration noted in the pts chart/? Right Ans - FNA
acronym for axial length? Right Ans - AL
acronym for BC Right Ans - base curve
what does BI indicate on a spectacle prescription? Right Ans - base-in
prism
what deos BUT stand for on a pt's chart regarding tear film? Right Ans -
break up time
acronym for CN Right Ans - cranial nerve
acronym for CV Right Ans - color vision
what does the notation for FTP indicate on a chart of a child with strabismus?
Right Ans - full time patch
what does the notation DR indicate regarding a pts condition? Right Ans -
diabetic retinopathy
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