AOC Documentation and Record Keeping 2 — Questions and Answers
Question 1: When documenting a cover test in a pediatric patient's chart, which finding should be recorded first?
- The direction of the deviation
- The distance at which the test was performed (Correct answer)
- Whether fixation was maintained
- The type of prism used for neutralization
Correct answer: The distance at which the test was performed
Documentation of cover test results should always specify the testing distance (near vs. far) before describing the deviation.
Question 2: Which abbreviation correctly documents an intermittent left exotropia at distance?
- X(T) OD sc
- X(T) OS cc
- X(T)' OS sc (Correct answer)
- X(T)' OU sc
Correct answer: X(T)' OS sc
X(T)' denotes intermittent exotropia at distance, OS indicates the left eye is the deviating eye, and sc means without correction.
Question 3: In orthoptic records, 'NPC' most commonly refers to which measurement?
- Negative prism convergence
- Near point of convergence (Correct answer)
- Normal pupillary constriction
- Nasal prism correction
Correct answer: Near point of convergence
NPC stands for near point of convergence, which measures the closest point at which both eyes can maintain single binocular vision.
Question 4: A patient's chart notes 'ET 18PD cc at near'. What does this mean?
- Esotropia of 18 prism diopters with correction at near distance (Correct answer)
- Exotropia of 18 prism diopters without correction at near distance
- Esotropia of 18 prism diopters without correction at near distance
- Exotropia of 18 prism diopters with correction at near distance
Correct answer: Esotropia of 18 prism diopters with correction at near distance
ET = esotropia, 18PD = 18 prism diopters, cc = with correction (cum correctione), at near specifies the test distance.
Question 5: Which element is essential when documenting stereopsis results in a clinical record?
- Patient's dominant eye
- The specific test used and threshold achieved (Correct answer)
- Room illumination level
- Examiner's name
Correct answer: The specific test used and threshold achieved
Stereopsis documentation must include both the test name (e.g., Randot, Titmus) and the threshold in seconds of arc, as different tests yield non-interchangeable results.
Question 6: When recording sensory status, 'NRC' indicates which condition?
- No retinal correspondence
- Normal retinal correspondence (Correct answer)
- Negative retinal convergence
- Null reflex center
Correct answer: Normal retinal correspondence
NRC stands for normal retinal correspondence, meaning the fovea of each eye shares the same visual direction.
Question 7: In electronic health records for orthoptic findings, the term 'SPCT' refers to which test?
- Stereoacuity prism cover test
- Simultaneous prism cover test (Correct answer)
- Single prism cross test
- Superior prism convergence test
Correct answer: Simultaneous prism cover test
SPCT (simultaneous prism cover test) is used to measure the objective angle in patients with anomalous retinal correspondence.
AOC Documentation and Record Keeping 2
When documenting a cover test in a pediatric patient's chart, which finding should be recorded first?