Ch 8: Principles of Effective Documentation

Question 1

An Emergency Medical Responder makes sure the receiving health-care professional is properly informed of the patient’s progression and care. This insures:
A. productive education.
B. continuity of care.
C. quality assurance.
D. legal precedence.

Answer 1

B. continuity of care.

Question 2

Which of the following is NOT part of the minimum data set that an Emergency Medical Responder should give when transferring care?

A. Name
B. Name of person at fault for injury C. Vital signs
D. Chief complaint

Answer 2

B. Name of person at fault for injury

Question 3

You are on a call with a patient who appears to be intoxicated. He is yelling profanity at you and your partner. He admits to drinking a fifth of whiskey over the day. Which of the following would be appropriate to document in your report?

A. The patient states he has had a “fifth of whiskey to drink.”
B. The patient is drunk and using inappropriate language.
C. The patient is violent and is probably intoxicated.
D. The patient has a bad attitude and is being rude to the crew.

Answer 3

C. The patient is violent and is probably intoxicated.

Question 4

Your patient care report may be called into a civil or criminal court due to the fact that:
A. any document may be presented.
B. it may be used to compile statistical data.
C. it contains personal patient information.
D. it is considered a legal document.

Answer 4

D. it is considered a legal document.

Question 5

It’s important to document thoroughly and accurately because:

A. patients expect a lengthy report.
B. if an action or intervention is not documented, it may be concluded that we did not actually perform an action or intervention.
C. the more that is documented, the more the patient can be billed.
D. lawycrs are intimidated by lengthy patient care reports.

Answer 5

B. if an action or intervention is not documented, it may be concluded that we did not actually perform an action or intervention.

Question 6

The is the part of the patient care report (PCR) in which the Emergency
Medical Responder documents that the patient has been turned over to an ambulance.
A. narrative
B. disposition
C. patient data
D. run data

Answer 6

D. run data

Question 7

The part of the patient care report that includes the patient’s name, address, date of birth, and sex is the:
A. patient data section.
B. run data section.
C. narrative section.
D. billing section.

Answer 7

A. patient data section.

Question 8

Which of the following is TRUE regarding narrative writing?

A. It should contain only subjective information.
B. It should contain conclusions you make from your observations.
C. It should contain the patient’s personal information.
D. It should contain both objective and subjective information.

Answer 8

D. It should contain both objective and subjective information.

Question 9

All of the following regarding correcting errors is true EXCEPT:
A. cross out the incorrect item with a single line.
B. always initial the correction.
C. white-out should be used.
D. never completely cover the incorrect information.

Answer 9

C. white-out should be used.

Question 10

Which of the following is NOT considered a form of electronic documentanhoan”
A. Tablet computer
B. Laptop computer
C. Writing on paper with a lighted pen D. Data-enabled cellular phone

Answer 10

C. Writing on paper with a lighted pen