documentation Flashcards
1) The subjective narrative includes information that is elicited:
A) during history taking.
B) from public records.
C) by observing the patient’s actions.
D) from dispatch information.
during history taking
2) The best method for completing the narrative section of the PCR is:
A) dependent on the nature of the call.
B) the CHART format.
C) the patient management format.
D) the SOAP format.
dependent on the nature of the call
3) An addition or a supplement to an original report is called a(n):
A) supplement.
B) add-on.
C) addendum.
D) appendix.
addendum
4) When your patient refuses care and transportation, even though you have communicated to the patient that you feel it is necessary, the patient is refusing:
A) against medical control (AMC).
B) with impaired decision-making (WID).
C) with informed consent (WIC).
D) against medical advice (AMA).
AMA
5) The paramedic’s general impression is documented in the:
A) subjective narrative.
B) assessment/management plan.
C) objective narrative.
D) diagnosis section.
objective narrative
6) Which of the following refers to the time between dispatch of a unit and its arrival on the scene?
A) On-scene
B) Response
C) Dispatch
D) Transport
response
7) What is the problem with the treatment in the following narrative?
The pt. complained of chest pain x 2 days before calling EMS and is now also c/o SOB. Vitals BP 90/50, HR 40, labored with retractions. Treated with O2 and atropine. Upon arrival the pt. felt better.
A) No dosages are stated.
B) The patient should have received transcutaneous pacing.
C) Nothing documented supports the treatment given.
D) A and C are both problematic.
A and C are both problematic
8) The format that uses a chronological account from the time of arrival on scene to the time of transfer of care is known as:
A) patient management.
B) body systems.
C) head-to-toe.
D) SOAP.
patient management
9) The only truly factual record of the events on an EMS call is the:
A) emergency department chart.
B) prehospital care report.
C) communications center report.
D) medical control report.
prehospital care report
10) Pertinent clinical information should be documented in the:
A) subjective narrative.
B) objective narrative.
C) treatment section.
D) clinical narrative.
objective narrative
11) An essential component of good documentation is the appropriate use of:
A) subjective opinions.
B) administrative research.
C) medical terminology.
D) medical metaphors.
medical terminology
12) Which of the following documents containing vital information is affixed to the patient during large-scale incidents with multiple patients?
A) MedicAlert tags
B) PCRs
C) MCI narratives
D) Triage tags
triage tags
13) What is the correct abbreviation for potassium?
A) K++
B) K-
C) K+
D) K
K+
14) Which of the following allows you to increase the amount of information you can quickly and efficiently write on your PCR?
A) Acronyms and abbreviations
B) Pertinent negatives
C) Time stamps
D) Medical terms
acronyms and abbreviations
15) Which of the following types of records provides the basis for continuous improvement of patient care in the EMS system?
A) EMS supervisor administrative reports
B) Medical control radio logs
C) Prehospital care reports
D) The dispatch center log
prehospital care reports
16) The prehospital care report should document all of the following, EXCEPT:
A) objective observations.
B) treatments provided.
C) pertinent negatives.
D) subjective opinions.
subjective opinions
17) You are completing your PCR and cannot remember the correct spelling of a medical term. You should:
A) try to spell the word, even if you are wrong.
B) make up an abbreviation for the word.
C) cross out the sentence and indicate an error.
D) use plain English instead.
use plain English instead
18) The abbreviation Hgb stands for:
A) millimeters of mercury.
B) hematocrit.
C) history.
D) hemoglobin.
hemoglobin
19) What is one of the common problems with documenting times?
A) Medical terminology
B) Abbreviations and acronyms
C) Inconsistencies between dispatch and ambulance clocks
D) Check boxes
inconsistencies between dispatch and ambulance clocks
20) Confidentiality of a patient’s prehospital care report is:
A) forfeited by the patient when he consents to treatment.
B) not applicable to patients who are not expected to survive.
C) not applicable to noncitizens.
D) the patient’s legal right.
the patients legal right
21) Which of the following individuals may make changes and additions to the original chart?
A) The medical direction physician
B) The original author’s partner
C) The original author
D) All of the above
the original author
22) Missing information, inaccurate data, and illegible documentation all give the impression of a(n):
A) incompetent provider.
B) busy shift.
C) typical EMS patient care report.
D) practiced paramedic whose reputation speaks for itself.
incompetent provider
23) You respond to a call and the police and fire departments are on the scene, as well as a physician. Which of the following should you mention in your PCR?
A) Fire department only
B) Fire department and the physician only
C) Police, fire, and the physician
D) Police only
police fire and the physician
24) A well-written prehospital care report is:
1. accurate.
2. legible.
3. without alterations.
4. professional.
A) 1 and 2 only
B) 1, 2, and 4
C) All of the above
D) None of the above
all of the above
25) When using direct patient statements, you should:
A) identify the quote with quotation marks.
B) have your partner or another witness initial the statement.
C) use the SOAP format.
D) have the patient initial his agreement with them, if his condition permits.
identify the quote with quotation marks
26) When possible, who should be asked to read and review the PCR before you submit it as complete?
A) Only you and your partner
B) Only you
C) Only you, your partner, and the patient
D) All EMS providers participating in patient care on the call
all EMS providers participating in patient care on the call
