COA Patient History and Documentation 3

Question 1

Which of the following is a component of the Social History section in an ophthalmic history?

Accepted Answer

Current smoking status and occupation

Answer

Amblyopia treated in childhood

Answer

Systemic hypertension

Answer

Use of topical glaucoma drops

Question 2

A patient's chart shows 'PCIOL OD' documented after a prior visit. What does this abbreviation indicate?

Accepted Answer

Posterior chamber intraocular lens implanted in the right eye

Answer

Primary congenital intraocular lesion in the right eye

Answer

Peripheral corneal inflammatory opacity in the left eye

Answer

Pupil constriction with intraocular light in the right eye

Question 3

The Review of Systems (ROS) in an ophthalmic history specifically asks about systemic symptoms. Which symptom, if present, would be MOST urgent to report to the physician before completing the eye exam?

Accepted Answer

Acute onset severe headache with nausea and halos around lights

Answer

Mild seasonal allergies

Answer

Dry skin in winter months

Answer

Occasional mild floaters for several years

Question 4

What does the abbreviation 'BCVA' stand for in an ophthalmic record?

Accepted Answer

Best corrected visual acuity

Answer

Bilateral central visual acuity

Answer

Baseline corneal visual assessment

Answer

Binocular corneal visual angle

Question 5

When recording the history of present illness (HPI) for a patient reporting blurred vision, which element describes the QUALITY of the symptom?

Accepted Answer

'Described as foggy, like looking through frosted glass'

Answer

'Started two weeks ago'

Answer

'Worsens when reading'

Answer

'Accompanied by mild eye redness'

Question 6

A patient denies taking any medications but mentions using 'natural eye drops for dryness' purchased at a health food store. How should the COA document this?

Accepted Answer

Document it under 'Current Medications' as an OTC/supplement product

Answer

Ignore it since it is not a prescription medication

Answer

List it under 'Social History' as a lifestyle choice

Answer

Record it only if the patient knows the exact brand name