FREE COA History Taking and Documentation Questions and Answers

Question 1

A patient calls stating they suddenly see 'flashing lights and a curtain' over the vision in their right eye.
Which of the following is the MOST appropriate action for the ophthalmic assistant to take?

Accepted Answer

Instruct the patient to come to the office for an emergency evaluation immediately.

Answer

Schedule the patient for the next available routine appointment.

Answer

Advise the patient to monitor the symptoms and call back if they worsen.

Answer

Document the call and place it on the physician's desk for review at the end of the day.

Question 2

When documenting the Chief Complaint (CC), the ophthalmic assistant should:

Accepted Answer

Record the primary reason for the visit in the patient's own words.

Answer

Interpret the patient's symptoms using proper medical terminology.

Answer

List all symptoms the patient has experienced in the last year.

Answer

Detail the suspected diagnosis based on the patient's description.

Question 3

A 68-year-old patient presents for a follow-up visit for glaucoma. As part of the history taking, which of the following questions is most critical to ask regarding their medication?

Accepted Answer

"Have you been using your eye drops as prescribed and when was your last dose?"

Answer

"Are you still using the same pharmacy?"

Answer

"Do you like the color of the bottle cap?"

Answer

"Did you bring your eye drop bottles with you today?"

Question 4

Which component of the patient's history includes information about conditions like diabetes, hypertension, and arthritis?

Accepted Answer

Past Medical History (PMH)

Answer

History of Present Illness (HPI)

Answer

Ocular History

Answer

Social History

Question 5

In the SOAP note format, where would the ophthalmic assistant's measurement of the patient's visual acuity and intraocular pressure be documented?

Accepted Answer

Objective

Answer

Subjective

Answer

Assessment

Answer

Plan

Question 6

A patient describes their main symptom as 'blurry vision'. To properly document the History of Present Illness (HPI), which of the following is the BEST follow-up question?

Accepted Answer

"Did this start suddenly or gradually?"

Answer

"Do you have a family history of blurry vision?"

Answer

"Are you allergic to any medications?"

Answer

"Have you had eye surgery in the past?"

A patient calls stating they suddenly see 'flashing lights and a curtain' over the vision in their right eye.Which of the following is the MOST appropriate action for the ophthalmic assistant to take?

A patient calls stating they suddenly see 'flashing lights and a curtain' over the vision in their right eye.
Which of the following is the MOST appropriate action for the ophthalmic assistant to take?