2.1 History and Documentation Overview
Key Takeaways
- History and Documentation is a defined content area on the Certified Ophthalmic Assistant (COA) exam, which has 200 multiple-choice questions in a 180-minute window at Pearson VUE.
- A complete ophthalmic history has seven parts: chief complaint, history of present illness, past ocular history, past medical history, medications, allergies, and family/social history.
- The chief complaint is recorded in the patient's own words with onset, duration, laterality, and severity; it is never a diagnosis or a technician observation.
- Standard abbreviations (OD, OS, OU, sc, cc, ph) must be used precisely because the chart is a legal record and drives the physician's exam.
2.1 History and Documentation Overview
History and Documentation is one of the foundational content areas on the Certified Ophthalmic Assistant (COA) examination administered by the International Joint Commission on Allied Health Personnel in Ophthalmology (IJCAHPO). The COA exam is a 200-question, multiple-choice test delivered in a 180-minute (3-hour) window at a Pearson VUE test center or by OnVUE remote proctoring.
Scoring is criterion-referenced (a scaled passing standard set by a modified-Angoff process), so you cannot rely on a fixed percentage; IJCAHPO does not publish a passing percentage, and the raw number of correct answers needed varies slightly by test form.
History and documentation questions reward precise, exam-specific knowledge, not the generic test-taking heuristics that pad weaker guides.
Why the chart matters
As a COA, the history you record is the first thing the ophthalmologist reads and is part of a legal medical record. An incomplete or sloppy history can send the physician down the wrong diagnostic path, so the exam tests whether you capture the right elements in the right form.
The seven components of an ophthalmic history
| Component | Abbreviation | What it captures |
|---|---|---|
| Chief complaint | CC | The reason for the visit in the patient's own words |
| History of present illness | HPI | Characterization of the CC (onset, duration, severity) |
| Past ocular history | POHx | Prior eye disease, surgery, trauma, glasses/contacts |
| Past medical history | PMHx | Systemic disease with ocular impact (diabetes, hypertension) |
| Medications | Meds | All systemic and ophthalmic drugs, including OTC and drops |
| Allergies | NKDA if none | Drug, food, and environmental reactions with the reaction type |
| Family / social history | FHx / SHx | Hereditary eye disease, occupation, smoking, UV exposure |
Recording the chief complaint correctly
The chief complaint is documented verbatim, quoting the patient where possible, and pairs the primary symptom with a timeline: "blurry vision in the right eye for 3 days." It should describe a symptom, never a diagnosis. "Patient has a cataract" is wrong as a CC because the assistant is not diagnosing; "patient reports glare and worsening night vision for 6 months" is correct. Avoid technician interpretations such as "appears to have reduced vision."
Standard abbreviations you must know cold
- OD = oculus dexter = right eye
- OS = oculus sinister = left eye
- OU = oculi uterque = both eyes
- sc = sine correctione = without correction (no glasses/contacts)
- cc = cum correctione = with correction
- ph = pinhole acuity
- VA = visual acuity; IOP = intraocular pressure
Visual acuity is charted as eye + correction status + Snellen fraction, e.g. "VA cc OD 20/25, OS 20/40, OU 20/20." Reversing OD and OS, or omitting whether correction was worn, is a classic charting error and a frequent distractor on the exam.
More high-frequency abbreviations
Beyond the basics, the exam expects fluency with the chart shorthand that fills a real record. Common entries include PERRL (pupils equal, round, reactive to light), EOM (extraocular movements), CF and HM (counting fingers and hand motion, used when acuity is worse than the chart can measure), LP/NLP (light perception / no light perception), and dosing terms such as qd (daily), bid (twice daily), tid (three times daily), qid (four times daily), and prn (as needed). When a stem buries one of these in a sentence, the question is testing whether you can read the chart at a glance.
Understand the Latin dosing terms but favor the clearest, safest form when you write them.
Expanding the chief complaint into a present illness
A single chief complaint is rarely enough. Once the patient names the problem, the COA expands it into the history of present illness by asking when it started, whether it is constant or comes and goes, which eye is affected, what makes it better or worse, and how severe it is. For example, a complaint of "blurry vision" becomes useful only when you learn it is in the right eye, has been present for three days, is worse at distance, and is associated with new floaters. That extra detail can be the difference between a routine refraction and an urgent dilated examination.
The exam frequently asks which follow-up question best characterizes a stated complaint, and the correct choice is the one that adds clinically meaningful detail rather than a question that simply repeats what the patient already said.
The history as a safety net
Because the chart drives every downstream decision, the history doubles as a safety net. Documenting that a patient takes a blood thinner, has a sulfa allergy, or has a family history of glaucoma can change the physician's examination, the choice of dilating or anesthetic drops, and even the surgical plan. A history that is merely fast but incomplete is a liability; a history that is thorough, ordered, and accurately abbreviated is what the COA exam rewards.
How questions appear
A typical item gives a short patient encounter and asks which entry is the best chief complaint, which abbreviation is correct, or which history element is missing. Pick the answer that is in the patient's words, uses the correct Latin abbreviation, and reflects what a COA (not a physician) may legitimately document. When two answers seem close, prefer the one that is most specific to the symptom and the eye named in the stem, and that records information rather than interpreting it.
Which entry is the best example of a properly documented chief complaint for an ophthalmic patient?
In ophthalmic documentation, what does the abbreviation 'OD' refer to?