Documentation

Question 1

What may researchers use your PCR data to do? (3)

Answer 1

• Cut costs
• Alter staffing
• Shorten response times

Question 2

If you do not know how to spell a word, what should you do?

Answer 2

Look it up or use another word

Question 3

What are pertinent negatives?

Answer 3

Negative findings

Question 4

What is an addendum? What should be included in the addendum?

Answer 4

An addition or supplement to the original report. The addendum should include:

• Date and time it was written
• Reason it was written
• Pertinent information

Question 5

What kind of approach do EMS systems more often use?

Answer 5

Head to toe approach

Question 6

What does SOAP stand for?

Answer 6

• Subjective
• Objective
• Assessment
• Plan

Question 7

What does CHART stand for?

Answer 7

• Chief complaint
• History
• Assessment
• Rx (treatment)
• Transport

Question 8

What 2 kinds of patients commonly refuse care?

Answer 8

-The person who is not seriously ill or injured and simply does not want to go to the hospital
-A person who needs the care, but will not accept it
(AMA-Against Medical Advice)

Question 9

What kind of vital information should be recorded on a triage tag? (5)

Answer 9

• Patients name
• Major injuries
• Vitals
• Treatment
• Priority (urgent, non-urgent)

Question 10

T or F: If you did not document it, you did not do it

Answer 10

True

Question 11

Who can you share patient information with? (4)

Answer 11

• Another health care provider who will continue care
• Third party billing companies
• Police (if it is relevant to a criminal investigation)
• Court (if it issues a subpoena)