OSC exam prep for your ophthalmic scribes

A note was signed by the physician yesterday. Today the physician realizes the laterality of a finding was transcribed incorrectly. What should the scribe do?

Once signed, a note is part of the legal record, so a correction goes in as a visible, dated addendum that references the original and preserves the audit trail. Overtyping a signed entry destroys that trail, a separate unlinked note leaves two conflicting versions with no cross-reference, and saving the correction for a verbal mention at the next visit leaves the wrong eye standing in the record in the meantime.

Pre-visit intake lists the patient's cataract surgery date as 2019. During today's visit, the patient tells the physician, "Actually, that surgery was in 2021, I remember because it was right after I retired." What should the scribe document?

When the patient corrects information during the encounter, the scribe records what was said today, since the correction is the more current account. Leaving the 2019 intake entry standing preserves a date the patient just corrected, averaging the two invents a year nobody stated, and charting both without resolution hands the next reader a conflict that was already settled in the room.

The physician dictates, "Vision without correction is 20/50 in the right eye, and with pinhole it improves to 20/25." Which of the following correctly documents this for the right eye?

"Without correction" is denoted sc (sine correctione), and the finding is specific to the right eye (OD). The entry using cc incorrectly denotes "with correction," and the entries charted as OS or OU use the wrong laterality.

The physician dictates: "Start moxifloxacin 0.5%, one drop in the right eye, four times a day." Which charted entry correctly reflects this order?

The order specifies the right eye (OD, not OS), the concentration as stated (0.5%, not 5%), and four times daily (qid, not tid). Only the entry reading moxifloxacin 0.5% OD qid matches all three elements exactly as dictated.

A patient quietly tells the physician about a personal issue and then says to the scribe, "please don't put that in my chart." What is the most appropriate scribe response?

What belongs in the chart is a clinical determination the physician directs, so the scribe neither omits at a patient's request nor overrides one. Agreeing on the spot and skipping what the physician later says removes clinically directed content, charting it in full against the physician's direction ignores that direction, and negotiating with the patient over inclusion puts the decision in the scribe's hands.