AOC Documentation and Record Keeping 3 — Questions and Answers
Question 1: When documenting versions, which grading scale is most commonly used in orthoptic practice?
- -4 to +4 scale (Correct answer)
- 0 to 10 scale
- 1 to 6 scale
- Percent grading from 0 to 100
Correct answer: -4 to +4 scale
Versions are graded on a -4 to +4 scale, where 0 is normal, negative values indicate underaction, and positive values indicate overaction.
Question 2: A chart entry reads 'V pattern ET 20PD primary, 8PD upgaze, 30PD downgaze'. What does this indicate?
- Greater esotropia in upgaze than downgaze
- Greater esotropia in downgaze than upgaze (Correct answer)
- Equal esotropia in all positions of gaze
- Larger deviation at distance than near
Correct answer: Greater esotropia in downgaze than upgaze
A V pattern describes a strabismus that is larger in downgaze than upgaze, which is consistent with the documented measurements.
Question 3: Which documentation practice is required when a parent provides history for a pediatric patient?
- Record must note that history was obtained from a proxy and identify the relationship (Correct answer)
- No special notation is needed
- The child must co-sign the record
- History must be repeated at the next visit
Correct answer: Record must note that history was obtained from a proxy and identify the relationship
When history is obtained from a third party, documentation must specify that information came from a proxy and identify who that person is (e.g., mother, guardian).
Question 4: What is the correct way to document a corrected error in a paper medical record?
- Use correction fluid to cover the error and rewrite
- Erase the error completely
- Draw a single line through the error, initial, and date it (Correct answer)
- Tear out the page and rewrite the entry
Correct answer: Draw a single line through the error, initial, and date it
Errors in paper records must be corrected by drawing a single line through the error while keeping it legible, then initialing and dating the correction.
Question 5: When documenting the Worth 4-Dot test, which response pattern indicates suppression of the right eye?
- Patient reports 5 dots
- Patient reports 2 red dots
- Patient reports 4 dots with red/green overlap
- Patient reports 3 green dots (Correct answer)
Correct answer: Patient reports 3 green dots
Seeing 3 green dots on the Worth 4-Dot test indicates suppression of the right eye, which normally sees the red dots through the red filter.
Question 6: In orthoptic documentation, 'ARC' with a documented angle less than the objective angle indicates which type?
- Normal retinal correspondence
- Harmonious anomalous retinal correspondence
- Unharmonious anomalous retinal correspondence (Correct answer)
- Paradoxical retinal correspondence
Correct answer: Unharmonious anomalous retinal correspondence
Unharmonious ARC occurs when the anomalous angle does not equal the objective strabismus angle, creating a discrepancy between the two measurements.
Question 7: Which piece of information is mandatory when documenting the results of a Maddox rod test?
- The brand of Maddox rod used
- Whether the rod was held horizontally or vertically and the test distance (Correct answer)
- Room lighting conditions
- The patient's cycloplegic refraction
Correct answer: Whether the rod was held horizontally or vertically and the test distance
Maddox rod documentation must specify rod orientation (horizontal or vertical) and testing distance because these factors determine whether a horizontal or vertical phoria is being measured.
AOC Documentation and Record Keeping 3
When documenting versions, which grading scale is most commonly used in orthoptic practice?