COA Patient History and Documentation 2

Question 1

When obtaining a patient history, which question is MOST important to ask when a patient reports sudden painless vision loss in one eye?

Accepted Answer

Have you had any recent head trauma or vascular events?

Answer

Sudden painless vision loss in one eye is a red flag for vascular events such as central retinal artery occlusion, retinal vein occlusion, or stroke. Asking about recent vascular events (TIA, hypertension crises) and trauma helps triage urgency and guides the physician.

Question 2

A patient states they use brimonidine drops twice daily. In the medical record, this would be documented under which section?

Accepted Answer

Current medications

Answer

Brimonidine is a topical alpha-2 agonist used to lower intraocular pressure. All topical and systemic medications a patient is currently taking should be listed in the 'Current Medications' section of the medical record.

Question 3

Which notation correctly documents a patient's visual acuity when they cannot read the largest letter on the Snellen chart even with their best spectacle correction?

Accepted Answer

CF (counting fingers)

Answer

When a patient cannot resolve the 20/400 optotype, testing progresses to counting fingers (CF) at a specified distance, then hand motion (HM), light perception (LP), and finally no light perception (NLP). The correct next documentation step is CF.

Question 4

What is the PRIMARY purpose of documenting the chief complaint at the start of an ophthalmic encounter?

Accepted Answer

To establish the reason for the visit in the patient's own words

Answer

The chief complaint is a brief statement, ideally in the patient's own words, describing the primary reason they sought care. It directs the focus of the entire encounter and is a legal and clinical requirement.

Question 5

A patient reports a family history of age-related macular degeneration (AMD). How should this be documented?

Accepted Answer

Under Family History noting the relationship and condition

Answer

Family history (FH) is the section used to record heritable or familial diseases among blood relatives. AMD has a genetic component, so documenting the affected family member's relationship (e.g., mother, sibling) and the condition under FH is the correct approach.

COA - Certified Ophthalmic Assistant Practice Test

COA - Certified Ophthalmic Assistant Practice Test

COA Patient History and Documentation 2