Patient History and Documentation Flashcards
6 cards from real COA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Patient History and Documentation flashcards as text
When obtaining a patient history, which question is MOST important to ask when a patient reports sudden painless vision loss in one eye?
Answer: Have you had any recent head trauma or vascular events?
Sudden painless vision loss in one eye is a red flag for vascular events such as central retinal artery occlusion, retinal vein occlusion, or stroke. Asking about recent vascular events (TIA, hypertension crises) and trauma helps triage urgency and guides the physician.
A patient states they use brimonidine drops twice daily. In the medical record, this would be documented under which section?
Answer: Current medications
Brimonidine is a topical alpha-2 agonist used to lower intraocular pressure. All topical and systemic medications a patient is currently taking should be listed in the 'Current Medications' section of the medical record.
Which notation correctly documents a patient's visual acuity when they cannot read the largest letter on the Snellen chart even with their best spectacle correction?
Answer: CF (counting fingers)
When a patient cannot resolve the 20/400 optotype, testing progresses to counting fingers (CF) at a specified distance, then hand motion (HM), light perception (LP), and finally no light perception (NLP). The correct next documentation step is CF.
What is the PRIMARY purpose of documenting the chief complaint at the start of an ophthalmic encounter?
Answer: To establish the reason for the visit in the patient's own words
The chief complaint is a brief statement, ideally in the patient's own words, describing the primary reason they sought care. It directs the focus of the entire encounter and is a legal and clinical requirement.
A patient reports a family history of age-related macular degeneration (AMD). How should this be documented?
Answer: Under Family History noting the relationship and condition
Family history (FH) is the section used to record heritable or familial diseases among blood relatives. AMD has a genetic component, so documenting the affected family member's relationship (e.g., mother, sibling) and the condition under FH is the correct approach.
When documenting allergies in an ophthalmic history, which information is MOST important to include beyond the allergen name?
Answer: The specific reaction experienced (e.g., rash, anaphylaxis, GI upset)
Knowing the type of reaction helps distinguish true allergies (immune-mediated, potentially life-threatening) from intolerances or side effects. This guides the physician in prescribing alternative medications safely.