Record Keeping

Question 1

• Records must be completed in ______
• be ______ by the practioner
• use only _____ pen for the days specific record
• be complete, ____, well organized, legible, and _____

Answer 1

• ink
• signed
• one
• accurate, accessible

Question 2

What is the Federal Trade Commission Eyeglasses Rule (FTC)

Answer 2

the pt has a right to obtain informatin related to his prescription for specs or contact lenses. give pt a copy even if they dont ask

Question 3

What does the problem oriented medical record (POMR) contain? 4 things

Answer 3

1. the defined database
2. the complete problem list
3. initial treatment plans
4. progress notes (SOAP notes)

Question 4

what kind of exam is the defined database used for

Answer 4

comprehensive examination

Question 5

what are 4 things included in a comprehensive exam

Answer 5

1. pt demographics
2. results of the tests you do on all pts
3. problem list
4. plan list

Question 6

what is SOAP format

Answer 6

subjective - signs, symptons, reasons
objective - all testing
asessment - todays diagnosis
plan - future

Question 7

what are progress notes used for

Answer 7

follow-up examinations

non comprehensive exams

Question 8

what format are progress notes done in

Answer 8

SOAP format

Question 9

what are 4 purposed of optometric records

1. facilitate ____
2. provide______
3. serve as -____
4. justify _______

Answer 9

1. facilitate pt management and good clinical decision making
2. provide a current, comprehensive account of care and treatmetn
3. serve as the doctor’s defense in court
4. justify fees collected from 3rd parties such as insurance companies

Question 10

what should be in a record

1. _____ of visit
2. pt ______ and other ______
3. _____ for visit
4. all ______ done and _________ including______
5. VA always done _______ and at _____ visi t
6. diagnosis/ _____
7. treatment/ _____
8. recommendations for _______
9. speicific pt ______ given
10. ______ to whom and when
11. ________ with whom and when
12. all reports of any ______ w/ pt or about pt

Answer 10

1. date of visit
2. pt name and other demographic info
3. reason for visit
4. all testing done and test results including auxililary tests (see attached form)
5. visual acuity ALWAYS done first at EVERY visit
6. diagnosis/assessment
7. treatment/management plan
8. follow-up care
9. education
10. referrals
11. follow-ups
12. communication

Question 11

_____ is always done first at every visit

Answer 11

habitual VA

Question 12

what is rtc

Answer 12

return to clinic