Recording Keeping Bullshit

Question 1

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

Answer 1

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

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 are 4 things included in a comprehensive exam

Answer 3

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

Question 4

what is SOAP format

Answer 4

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

Question 5

what kind of exam is the defined database used for

Answer 5

comprehensive examination

Question 6

what are progress notes used for

Answer 6

follow-up examinationsnon comprehensive exams

Question 7

what are 4 purposed of optometric records 1. facilitate ____2. provide______3. serve as -____4. justify _______

Answer 7

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 8

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 t6. 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 8

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
6. treatment/management plan
7. follow-up care
8. education
9. referrals
10. follow-ups
11. communication

Question 9

what format are progress notes done in

Answer 9

SOAP format

Question 10

_____ is always done first at every visit

Answer 10

habitual VA

Question 11

what is rtc

Answer 11

return to clinic