History Taking, Communicatyion and Documentation

Question 1

What should a comprehensive history contain?

Answer 1

Data

Chief complaint

Allergies

Medication

Past medical history

Last meal intake

Events

Question 2

When can you use the mnemonic OPQRST?

Answer 2

For any pain related complaint.

Question 4

What is ther SOAP format?

Answer 4

A memory aid used to organize written and verbal patient reports, it include subjective data, objective data, assessment data and plan of patient management.

Question 5

What are the phases of communication?

Answer 5

• Occurance of the event
• Detection of the need of EMS
• Notification and emergency response
• EMS arrival, treatment and preparation for transport
• Preparation of EMS for the next response

Question 6

When assessing chief complaint in paediatrics, what questions must you ask?

What question can you ask when assessing the cheif complaint in paediatics?

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Answer 6

• Nature of the illness or injury
• The lenght of ollness of injury
• Last meal intake
• Presence of fever
• Effects on behavior
• Vomiting or diarrhea
• Frequancy of urination

Question 7

————- and ———- can provide the most imformation

Answer 7

School-age and adolescents

Question 8

What is the importance of proper history taking?

Answer 8

• Offer structure in the patient assessment
• Often sets priorities in patient care

Question 9

What factors can affect history taking?

Answer 9

• Silent
• Talkative patients
• Multiple symptoms
• Anxious, angry, hostile patients
• Intoxication
• Crying, depression
• Sexually attractive
• Sedutive patients
• Communication barriers e.g speech , sight and hearing impairment

Question 10

What question do you ask in a female patient complain about abdominal pain?

Answer 10

• OPQRST
• Site of the pain
• Localised or diffused pain
• LNMP
• Sexual status
• Any vaginal discharges( offensive) or bleeding

Question 11

What must you be cautious about when taking history from younger patients?

Answer 11

• Its not always reliable.
• When the parents are arround
• Takin drugs and alcohol

Question 12

What is importance of asking social history?

Answer 12

• It may suggest a possible diagnosis to illness e.g smoking, drinking, drug abuse etc
• It may enhance or alter your treatment therapy

Question 13

Importance of taking family history?

Answer 13

• Some disese can be hereditary and are passed on from generation to generation e.g DM, cancer

Question 14

Why is the important to ask and document the occupation of the patient?

Answer 14

• Work related stress
• Working environment that may contribute the current illness
• Susceptability and resistance to diseases and medication
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Question 15

Elements of comprehansive history taking?

Answer 15

• Dispatch imformation
• Chief complaint
• Family history
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Question 16

What difficulties you may encounter in patients with respiratory problems?

Answer 16

• They matbe unable to talk or talk in phrases.

Question 17

What is the best way to ask questions in patients who are respiratory distress?

Answer 17

• Ask open ended question and allow patients to tell their own story.
• Give them enough time to talk
• Ask the fimily members or bystanders

Question 18

What is the use of patient care report form?

Answer 18

• To document the key elements of patients assessment, care, and transport

Question 19

What are the 3 primary reason for a written documentation?

Answer 19

• Legal record
• Data records
• Used by medical practioners to document their traetment and diagnosis

Question 20

What is the necessary information needed from the first responder in a major incident?

Answer 20

METHANE AND HAZMAT REPORT