Ch.4 Flashcards
Which one of the following belongs in the patient narrative section of the prehospital care report (PCR)? A.Location of the patient B.Insurance and billing information C.Chief complaint D.Care given prior to arrival
C.Chief complaint
Which one of the following is an administrative use for the prehospital care report (PCR)? A.Quality improvement B.Preparing bills C.Legal defense D.Research
B.Preparing bills
Of the following suspicions that the EMT may develop when caring for a patient, which is most likely to necessitate the need for the EMT to complete a special report relative to the patient’s condition?
A.That the patient might refuse care.
B.A mechanical problem with his or her vehicle.
C.That the patient was not being honest.
D.That an elderly patient has been abused.
D.That an elderly patient has been abused.
Which of the following terms describes inaccurate information that has been documented on a PCR, and may lead to revocation of EMT certification as well as possible criminal charges? A.Inaccurate B.Incomplete C.Confidential D.Falsified
D.Falsified
TIA is a commonly accepted abbreviation for: A.Transported in ambulance. B.Transient ischemic attack. C.Tube in airway. D.Telephoned in advance.
B.Transient ischemic attack.
What organization developed the information that is to be included in the PCR minimum data set?
A.U.S. Department of Transportation
B.Social Security Administration
C.U.S. Department of Education
D.U.S. Department of Health and Human Services
A.U.S. Department of Transportation
Which of the following situations would be most likely to require that the EMT provide additional documentation beyond the traditional PCR?
A.The patient was a child.
B.The patient died en route to the hospital.
C.The patient did not need EMS.
D.The patient was abused or neglected.
D.The patient was abused or neglected.
Which of the following would NOT be appropriate when completing a PCR?
A.Documenting only facts about the patient
B.Using abbreviations you have developed
C.Using accepted medical abbreviations
D.Using anatomical language
B.Using abbreviations you have developed
The EMT is completing documentation for the prehospital care report (PCR) and documents: "Patient states, 'Upon walking up the stairs, I became short of breath.'" Which type of information would this be considered? A.Objective information B.Subjective information C.Pertinent negatives D.Patient medical history
B.Subjective information
What type of PCR format requires the EMT to document patient information with an ink pen or other similar writing instrument? A.Electronic clipboard report B.Hybrid computer report C.Traditional computer report D.Traditional written report
D.Traditional written report
Remember this EMS saying when filling out reports: "If it was not done, do not: A.do it." B.say it." C.write it down." D.pretend it was."
C.write it down.”
Which of the following is NOT a component of the minimum data set?
A.Insurance information
B.Skin color, temperature, and condition
C.Chief complaint
D.Blood pressure
A.Insurance information
What is the prime reason for high-quality documentation? A.Legal defense B.Education and research C.Billing purposes D.High-quality patient care
D.High-quality patient care
Which of the following is NOT accurate when completing the vital signs division of the PCR?
A.Document the position the patient was in when vitals were taken.
B.At least two complete sets of vital signs should be taken and recorded.
C.Document the time the patient’s vital signs were taken.
D.If you only take one set of vital signs, the second may be estimated.
D.If you only take one set of vital signs, the second may be estimated.
What is the name of the document in which the EMT should document all patient findings and treatment? A.Triage tag B.General use statement C.Medical chart D.PCR
D.PCR
When utilizing the SOAP mnemonic for documentation, what does the "A" stand for? A.Accidents B.Assessment C.Agitation D.Actions
B.Assessment
Subjective, Objective, Assessment, and Plan
Which of the choices is necessary for ensuring that the minimum data set is as accurate as possible?
A.Use of integrated clipboard PCR formats
B.Use of paper PCR
C.Use of computer-based PCR
D.Use of accurate and synchronous clocks
D.Use of accurate and synchronous clocks
You are giving a presentation to a group of new hires about your system’s computer-based patient care report system. What might you identify as the greatest benefit of this system?
A.It creates more legible written reports.
B.It is the most common type of reporting system used today.
C.It is cheaper than paper reports.
D.It eliminates the need for the EMT to have a pen handy.
A.It creates more legible written reports.
The "P" in the mnemonic SOAP stands for: A.provocation. B.palliation. C.pain. D.plan.
D.plan.
Which of the following bits of information should NOT be found in the treatment section of a patient care report?
A.Subjective interpretation about the treatment rendered
B.What treatments were rendered
C.Indications of how the patient responded to treatments
D.What time treatments were rendered
A.Subjective interpretation about the treatment rendered
When utilizing the CHART mnemonic for documentation, where is the treatment provided to the patient documented? A. A B. R C. H D. T
B. R
Which one of the following situations would require a special report? A.Childbirth B.DOA C.Medical direction contact D.Gunshot wounds
D.Gunshot wounds
What does the medical abbreviation "CF" stand for? A.Cystic fibrosis B.Common finding C.Collarbone fracture D.Congestive failure
A.Cystic fibrosis
The patient's description of the mechanism of injury belongs in which one of the following sections? A.Patient demographics B.Administrative information C.Vital signs D.Patient narrative
D.Patient narrative
What is the value of documenting a pertinent negative on your PCR?
A.It demonstrates that the patient was alert.
B.The lack of the symptom is relevant to the assessment.
C.It shows you know to ask lots of questions.
D.It helps fill up the narrative portion of the form.
B.The lack of the symptom is relevant to the assessment.
The United States Department of Transportation’s minimum data set for patient information gathered by the EMT includes:
A.capillary refill for patients less than three years old.
B.the patient’s respiratory rate and effort.
C.systolic blood pressure for patients greater than one year old.
D.the patient’s medical insurance information.
B.the patient’s respiratory rate and effort.
Which of the choices is an advantage of the paper-based charting system?
A.The user typically has more freedom on the type of information entered, including writing style.
B.The user can just rip up a PCR they made an error on, and start a new one.
C.Since the paper system cannot connect to monitoring equipment, it is easier to use.
D.The paper system will not fail if the PCR is accidentally left out in the rain.
A.The user typically has more freedom on the type of information entered, including writing style.
Which of the following components is in the patient demographics section of the PCR? A.Any allergies to medications. B.The patient's family doctor. C.The patient's chief complaint. D.The patient's home address.
D.The patient’s home address.
What is the prime reason for high-quality documentation? A.Education and research B.High-quality patient care C.Legal defense D.Billing purposes
B.High-quality patient care
In a multiple-casualty incident, the patient's name and chief complaint are recorded on a: A.field note. B.triage tag. C.mobile data unit. D.mini PCR.
B. triage tag
What is an advantage of the computerized report over the traditional written report?
A.It can be linked to diagnostic and monitoring equipment.
B.It does not require the entry of as many sets of vital signs during patient contact.
C.It requires the EMT to use proper spelling, as the report will be saved as is.
D.The computer form is a scanned version of a paper form that is easier and cheaper to archive.
A.It can be linked to diagnostic and monitoring equipment.
What is a primary difference in the type of information found in the administrative section and in the patient information section of the PCR?
A.The patient information includes the patient’s address only, and the administrative section includes the trip times.
B.The patient information includes the patient assessment information, and the administrative section includes the name and address of the EMS system.
C.The patient information includes specific assessment findings, and the administrative information includes the trip times.
D.The patient information includes the chief complaint, and the administrative information includes the EMS arrival time.
C.The patient information includes specific assessment findings, and the administrative information includes the trip times.
What is the MOST widely used format for creating patient care reports in EMS? A.Electronic clipboard PCR format B.Smartphone PCR application format C.Paper PCR format D.Computer-based PCR format
D.Computer-based PCR format
The first "E" in the mnemonic CHEATED stands for: A.exam. B.effort. C.evaluation. D.extremity.
A. exam
(Chief Complaint, History, Examination, Assessment, Treatment, Evaluation (Did the treatment help?), Disposition (What was the final outcome?)
Why are all PCRs done in the United States today supposed to have the minimum data set included?
A.This allows better research and standardization of EMS care.
B.It is required for Medicaid and Medicare to provide reimbursement.
C.It allows the tracking of information to ensure the elderly population is managed correctly.
D.It shortens the overall length of the PCR.
A.This allows better research and standardization of EMS care.
The EMT’s ability to accurately and completely record patient information is important not only for the continuity of care, but also for what other purpose?
A.To ensure that the patient was treated ethically
B.To aid the quality improvement process
C.To demonstrate the need for upgrading to an ALS service
D.To account for all patient equipment that was used
B.To aid the quality improvement process
You are working with a new EMT hire at your EMS company. You are showing him how to use the mobile data units when creating a PCR. He asks you why a PCR is even necessary. What should NOT be part of your answer?
A.It is a legal document that stays with the patient’s medical records.
B.It has administrative purposes.
C.It is intended to document the care provided.
D.It is used as a document to identify when the EMT should be disciplined.
D.It is used as a document to identify when the EMT should be disciplined.
What type of special reporting situation typically employs the use of triage tags?
A.Multiple-casualty incidents (MCIs) scenes
B.Sporting event scenes
C.Crime scenes
D.Paediatric arrest scenes
A.Multiple-casualty incidents (MCIs) scenes
Which of the choices is the proper abbreviation for "cardiovascular"? A.CVX B.CRDVAS C.CV D.CRVX
C.CV
An EMT documenting the assistance to a patient for taking a medication without the approval of medical direction is an example of what type of error? A.Permission B.Abandonment C.Omission D.Commission
D.Commission
Which section creates a thorough picture of the patient and his problem? A.Treatment B.Vital signs C.Administrative information D.Patient narrative
D.Patient narrative
While transcribing the names of medications from the patient's bottles to your patient care report, you find a medicine bottle that is labelled as "APAP". What does this mean? A.Naproxen B.Tylenol C.Aspirin D.Ibuprophen
B.Tylenol
What is an example of improper documentation on a patient care report?
A.Whether the patient thought the EMS providers acted appropriately.
B.Interventions and response to interventions.
C.Trends in the patient’s condition.
D.Information from the scene.
A.Whether the patient thought the EMS providers acted appropriately.
“SOAP,” “CHART,” and “CHEATED” are all methods to help the EMT accomplish what task?
A.Proper spinal immobilization
B.Proper documentation of special reporting forms used in EMS
C.Proper documentation on the PCR
D.Proper verbal communication with the receiving facility
C.Proper documentation on the PCR
Which EMS systems should be collecting the minimum data set on all emergency runs? A.All EMS systems B.Private EMS systems C.Third service public EMS systems D.Fire-based EMS systems
A.All EMS systems
When taking a history from the patient who is complaining of chest pain, a pertinent negative would include: A.the lack of prior heart attacks. B.the absence of breathing difficulty. C.his taking nitro and ASA. D.the lack of a history of allergies.
B.the absence of breathing difficulty.
A 24-year-old man was the driver in a car crash. The skin over his collarbone is red and swollen, but he tells you that it doesn't hurt. This is best described as a: A.pertinent negative. B.distracting injury. C.missing complaint. D.spinal injury.
A.pertinent negative.
