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.
