Chapter 6: Documentation Flashcards
Which of the following is a subjective finding?
A) Pale, cool, clammy skin
B) Obvious respiratory distress
C) A complaint of chest pressure
D) Blood pressure of 110/60 mm Hg
C) A complaint of chest pressure
All of the following are subjective findings, EXCEPT:
A) visible blood in the ear canal.
B) a feeling of impending doom.
C) a persistent dull headache.
D) acute and severe nausea.
A) visible blood in the ear canal.
The patient care report:
A) provides for a continuum of patient care upon arrival at the hospital.
B) is a legal document and should provide a brief description of the patient.
C) should include the paramedic’s subjective findings or personal thoughts.
D) is only held for a period of 24 months, after which it legally can be destroyed.
A) provides for a continuum of patient care upon arrival at the hospital.
Which of the following statements contains objective and subjective information?
A) “The patient’s behavior was consistent with alcohol intoxication.”
B) “The patient’s pulse was rapid and weak and he was diaphoretic.”
C) “The patient’s wife stated that he began feeling ill a few hours ago.”
D) “The patient appeared confused and stated that he had a headache.”
D) “The patient appeared confused and stated that he had a headache.”
If a patient with decision-making capacity adamantly refuses treatment for an injury or condition that clearly requires immediate medical attention, the paramedic should:
A) request law enforcement assistance at once.
B) contact online medical control for guidance.
C) make other arrangements for patient transport.
D) ask the patient to sign a refusal of treatment form.
B) contact online medical control for guidance.
When a competent adult patient refuses medical care, it is MOST important for the paramedic to:
A) ensure that the patient is well informed about the situation at hand.
B) contact medical control and request permission to obtain the refusal.
C) perform a detailed physical exam before allowing the patient to refuse.
D) obtain a signed refusal from the patient as well as a witness signature
A) ensure that the patient is well informed about the situation at hand.
Components of a thorough patient refusal document include:
A) assurance by the paramedic that the patient’s ability to pay is of no concern.
B) notification of the patient’s physician to apprise him or her of the situation.
C) documentation of a complete assessment, even if the patient refused assessment.
D) willingness of EMS to return to the scene if the patient changes his or her mind
D) willingness of EMS to return to the scene if the patient changes his or her mind
In order to ensure that all recorded times associated with an incident are accurate, the paramedic should:
A) frequently glance at his or her watch.
B) radio the dispatcher after an event occurs.
C) document the time that each event occurs.
D) get a copy of the dispatch log after the call.
B) radio the dispatcher after an event occurs.
The accuracy of your patient care report depends on all of the following factors, EXCEPT:
A) including all pertinent event times.
B) the severity of the patient’s condition.
C) the thoroughness of the narrative section.
D) documenting any extenuating circumstances.
B) the severity of the patient’s condition.
If you receive another call before completing the patient care report accurately for the previous call:
A) you should submit what you have completed to the receiving facility.
B) pertinent details about the previous call may be omitted inadvertently.
C) your patient care report must be completed within 36 hours after the call.
D) you should ask the dispatcher to send another paramedic crew to the call
B) pertinent details about the previous call may be omitted inadvertently.
Prior to submitting a patient care report to the receiving hospital, it is MOST important for:
A) your partner to review the report to ensure accuracy.
B) the EMS medical director to review the report briefly.
C) the paramedic who authored the report to review it carefully.
D) the quality assurance team to review the report for accurac
C) the paramedic who authored the report to review it carefully.
An accurate and legible patient care report:
A) should be complete to the point where anyone who reads it understands exactly what transpired on the call.
B) is not possible on every call, especially if there is more than one patient or the patient is critically ill or injured.
C) is a relatively reliable predictor of the quality of care that the paramedic provided to the patient during the call.
D) provides immunity to the paramedic if the patient decides to pursue legal action against the paramedic.
A) should be complete to the point where anyone who reads it understands exactly what transpired on the call.
The MOST significant problem associated with making up your own medical abbreviations and documenting them on the patient care report is:
A) insurance denial.
B) a potential lawsuit.
C) an error in patient care.
D) confusion at the hospital.
C) an error in patient care.
If you make an error when completing a written patient care report, you should:
A) circle the error, initial it, and write the correct information next to it.
B) not alter the original patient care report and write the correct information on an addendum.
C) use different colored ink when drawing a single line through the error.
D) leave the error, but write the correct information in parentheses next to it.
C) use different colored ink when drawing a single line through the error.
