4 Documentation

Question 1

What is the purpose of a patient care report?
A.
Helps supervisors keep track of crews
B.
Provides a legal record of the incident
C.
Documents who called for the response
D.
States what dispatcher dispatched the crews

Answer 1

B

Question 2

What is a common use of the patient care report?
A.
Assist with quality improvement
B.
Document the dispatcher who took the call
C.
To share with patient’s family and friends
D.
Disciplinary tool for supervisors

Answer 2

A

Question 3

Where should a clear and concise chronological description of a call be documented on the prehospital care report?
A.
Heading boxes
B.
Narrative portion
C.
Under the mechanism of injury or event
D.
On a supplemental report form

Answer 3

B

Question 4

When completing a prehospital care report, how should the area for administrative and billing information be handled?
A.
It is the responsibility of the billing department, not the EMS provider.
B.
It is separate from the legal record.
C.
It is part of the form and should be completed accurately.
D.
It has a minimal effect on the financial viability of the EMS agency.

Answer 4

C

Question 5

How should paramedics handle statements or remarks made by patients or bystanders that might be pertinent to medical care?
A.
Document as quotes.
B.
Document as factual statements.
C.
Report to the receiving medical facility without prehospital care report documentation.
D.
Report to police at the scene.

Answer 5

A

Question 6

The prehospital care report contains the quoted sentence, “He was driving at least ninety miles per hour.” What does the statement signify?
A.
The EMS providers witnessed the car traveling at 90 miles per hour.
B.
Police reports verify that the car was traveling at 90 miles per hour.
C.
Damage to the car suggests the patient was traveling at 90 miles per hour.
D.
Bystanders report the patient was traveling at 90 miles per hour.

Answer 6

D

Question 7

You are called for a patient complaining of difficulty breathing. How should the patient’s statement(s) about the symptoms be documented?
A.
Rephrase the patient’s statements in medical terms.
B.
Use quotation marks to indicate the statement was that of the patient.
C.
Avoid using the patient’s words; document only vital signs and your physical examination findings.
D.
Use quotation marks to indicate that the statement is that of the patient—as closely as you can remember it.

Answer 7

B

Question 8

How can errors involving the use of abbreviations be prevented when charting?
A.
Never using abbreviations
B.
Placing all abbreviations in quotes
C.
Avoiding abbreviations that are not universally accepted
D.
Using abbreviations only when documenting a patient’s statement

Answer 8

C

Question 9

While transporting a patient with severe chest pain, you realize that you haven’t taken a set of vital signs for more than 30 minutes. How should you handle this situation?
A.
Document the vital signs taken at the patient’s home as the vital signs during transport.
B.
Document the reasons for the omission of taking vital signs.
C.
Take vital signs immediately and document them as though they had been taken 15 minutes earlier.
D.
Contact medical direction for advice.

Answer 9

B

Question 10

Which term best describes assessment findings, such as the absence of diminished breath sounds, and warrants no medical care or intervention but shows evidence of a thorough examination?
A.
Essential findings
C.
Pertinent negatives
B.
Assessment norms
D.
Relevant positives

Answer 10

C

Question 11

Which acronym is a correct part of the SOAP format?
A.
S = Signs
C.
A = Assessment data
B.
O = Observations
D.
P = Patient history

Answer 11

C

Question 12

Which term best describes information supported by fact or direct observation?
A.
Subjective information
C.
Objective information
B.
Clinical facts
D.
Direct information

Answer 12

C

Question 13

Information such as ECG, pulse oximetry, and blood glucose readings belong where in the SOAP documentation format?
A.
S
C.
A
B.
O
D.
P

Answer 13

B

Question 14

In the CHART format for documentation, where is treatment rendered from standing orders or protocols documented?
A.
C
C.
A
B.
H
D.
R

Answer 14

D

Question 15

How should the paramedic handle a situation in which a child’s behavior or the history of an event is suspicious for possible physical or sexual abuse in the home?
A.
Take the child into protective custody.
B.
Notify Child Protective Services from the scene.
C.
Ask the police to transport the child.
D.
Carefully document his or her observations, and report them to medical direction.

Answer 15

D

Question 16

How should a paramedic document a patient who refuses EMS treatment or transport?
A.
Carefully document the events, assessments, and recommendations to patients.
B.
Contact medical direction to have them document the events.
C.
There is no need to document the EMS response.
D.
Documentation is required only if you feel the patient refused care inappropriately.

Answer 16

A

Question 17

How should a paramedic document the events during a major incident involving several patients?
A.
Documentation for each patient should be completed by the Incident Commander.
B.
One general report for the incident and all patients should be produced.
C.
Comprehensive documentation might have to be postponed until all patients are triaged and transported.
D.
Brief documentation for each patient should be completed by the staging sector officer.

Answer 17

C

Question 18

What should the paramedic do if the EMS response is cancelled en route to the scene?
A.
Return to the station; no documentation is necessary.
B.
Contact medical direction for advice.
C.
Document who cancelled the response and the time of the cancellation.
D.
Request dispatchers to document the events.

Answer 18

C

Question 19

How should the paramedic handle an omission in the prehospital care report?
A.
Note the purpose of the revision or correction and why the information did not appear on the original document.
B.
Scratch out the wrong information and write the correct information beside it.
C.
Write a revision on a carbon copy of the original form.
D.
Use a U.S. Department of Transportation-approved supplement form to rewrite.

Answer 19

A

Question 20

How should the paramedic correct an incorrect entry on a prehospital care report?
A.
Tear up the prehospital care form, and start over with a new one.
B.
Erase the entry, and write the new entry in its place.
C.
Mark through the entry with a black permanent marker, and write the new entry nearby.
D.
Draw a single horizontal line through the entry so that it remains legible, and date and initial it.

Answer 20

D

Question 21

What step should the paramedic implement to ensure a properly written report?
A.
Have a co-worker proofread any written supplements.
B.
Assume responsibility for self-assessment of all documentation.
C.
Limit charting and documentation activity until after he or she is rested.
D.
Mimic the style of another paramedic.

Answer 21

B

Question 22

How can a paramedic help facilitate quality-improvement reviews and ensure the completeness of the prehospital care report?
A.
Use a standard format established or approved by medical direction.
B.
Always complete a supplemental report form.
C.
Print all important items on the forms.
D.
Have risk management review the prehospital care report.

Answer 22

A