Exam 10: Documentation

When possible, who should be asked to read and review the PCR before you submit it as complete?

Which of the following refers to the time between dispatch of a unit and its arrival on the scene?

When using direct patient statements, you should:

A well-written prehospital care report is: 1. accurate. 2) legible. 3) without alterations. 4) professional.

An accurate prehospital care report includes all of the following, EXCEPT:

Use of prehospital care reports for quality improvement is an example of their ________ use.

Which of the following words is an example of proper medical terminology?

The prehospital care report should document all of the following, EXCEPT:

One common pattern for organizing a narrative report is identified by the mnemonic:

Which of the following individuals may make changes and additions to the original chart?

If a legal case is brought against you, your best defense in court is usually:

When using a prehospital care report for research or quality assurance, you should block out the:

An addition or a supplement to an original report is called a(n):

You are allowed to share the information in patient charts with all of the following, EXCEPT:

Under what circumstances should paramedics try to hide charting errors?

Which of the following types of records provides the basis for continuous improvement of patient care in the EMS system?

Confidentiality of a patient's prehospital care report is:

Which is the most important reason for NOT trying to complete the PCR during the ride to the hospital?

An essential component of good documentation is the appropriate use of:

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.