COM Clinical Documentation & Records 3

Question 1

In orofacial myology records, what does a nasal airway obstruction notation typically prompt the clinician to document as a referral recommendation?

Accepted Answer

Otolaryngologist (ENT)

Answer

Documented nasal obstruction findings should trigger an ENT referral notation because open-mouth posture and mouth breathing are directly linked to nasal patency issues.

Question 2

Which component of the initial evaluation record captures the patient's own description of their orofacial concerns?

Accepted Answer

Chief complaint / subjective history

Answer

The chief complaint and subjective history section uses the patient's own words to document why they are seeking orofacial myology services.

Question 3

When documenting a swallowing pattern, the notation 'anterior tongue thrust with lip seal' indicates which finding?

Accepted Answer

Tongue protrudes anteriorly between or against teeth during swallow but lips close

Answer

An anterior tongue thrust with lip seal means the tongue pushes forward against or between the front teeth during swallowing, but the lips remain closed throughout the swallow.

Question 4

What is the primary purpose of baseline standardized photographs taken at the initial COM evaluation?

Accepted Answer

To provide a comparison reference for measuring treatment progress

Answer

Baseline standardized photographs establish a visual reference point that allows objective comparison of structural and functional changes throughout and after treatment.

Question 5

A minor patient's parent revokes previously given consent for treatment. What is the appropriate documentation response?

Accepted Answer

Document the revocation in writing, date it, and cease treatment accordingly

Answer

Consent revocation must be documented immediately with date, circumstances, and signature, and treatment must be modified or stopped to reflect the current consent status.

(COM) Certified Orofacial Myologist Practice Test

(COM) Certified Orofacial Myologist Practice Test

COM Clinical Documentation & Records 3