COA Patient History and Documentation 2

Question 1

When obtaining a patient history, which question is MOST important to ask when a patient reports sudden painless vision loss in one eye?

Accepted Answer

Have you had any recent head trauma or vascular events?

Answer

Do you wear contact lenses?

Answer

When did you last have your glasses updated?

Answer

Do you have a family history of glaucoma?

Question 2

A patient states they use brimonidine drops twice daily. In the medical record, this would be documented under which section?

Accepted Answer

Current medications

Answer

Chief complaint

Answer

Review of systems

Answer

Assessment and plan

Question 3

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?

Accepted Answer

CF (counting fingers)

Answer

20/400

Answer

HM (hand motion)

Answer

LP (light perception)

Question 4

What is the PRIMARY purpose of documenting the chief complaint at the start of an ophthalmic encounter?

Accepted Answer

To establish the reason for the visit in the patient's own words

Answer

To record the patient's insurance information

Answer

To list all prior ocular surgeries

Answer

To document the physician's preliminary diagnosis

Question 5

A patient reports a family history of age-related macular degeneration (AMD). How should this be documented?

Accepted Answer

Under Family History noting the relationship and condition

Answer

Under Review of Systems as a positive finding

Answer

Under Past Medical History as a chronic condition

Answer

Under Social History as an environmental risk factor

Question 6

When documenting allergies in an ophthalmic history, which information is MOST important to include beyond the allergen name?

Accepted Answer

The specific reaction experienced (e.g., rash, anaphylaxis, GI upset)

Answer

The pharmacy where the allergy was first treated

Answer

The patient's insurance formulary

Answer

The date the patient first noticed the allergy