Deck 10: Documentation

Question 1

Pertinent clinical information should be documented in the:

A) subjective narrative.
B) objective narrative.
C) treatment section.
D) clinical narrative.

Answer 1

objective narrative.

Question 2

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

Answer 2

Triage tags

Question 3

What is the correct abbreviation for potassium?

A) K⁺⁺
B) K^-
C) K⁺
D) K

Answer 3

K⁺

Question 4

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.

Question 5

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.

Question 6

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

A) supplement.
B) add-on.
C) addendum.
D) appendix.

Question 7

The paramedic's general impression is documented in the:

A) subjective narrative.
B) assessment/management plan.
C) objective narrative.
D) diagnosis section.

Question 8

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.

Question 9

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

Question 10

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.

Question 11

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.

Question 12

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

Question 13

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).

Question 14

The abbreviation Hgb stands for:

A) millimeters of mercury.
B) hematocrit.
C) history.
D) hemoglobin.

Question 15

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

A) objective observations.
B) treatments provided.
C) pertinent negatives.
D) subjective opinions.

Question 16

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.

Question 17

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

Question 18

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

Question 19

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.

Question 20

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

A) subjective opinions.
B) administrative research.
C) medical terminology.
D) medical metaphors.

Question 21

The narrative format that focuses on immediate management of a variety of patient problems is called:

A) body systems.
B) SOAP.
C) patient management.
D) objective-subjective.

Question 22

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

A) Your time is better spent performing ongoing assessments.
B) You must communicate with the medical control physician.
C) There is an increased chance of error.
D) The ride is bumpy and the chart will be illegible.

Question 23

The narrative approach that focuses only on the areas involved in the current illness or injury is the ________ approach.

A) body systems
B) toe-to-head
C) focused exam
D) head-to-toe

Question 24

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

Question 25

Which of the following would be most useful for paramedics to carry with them as an aid to proper documentation?

A) Pocket-sized thesaurus
B) Copy of previous charts
C) Pocket-sized medical dictionary
D) Quality assurance policy

Question 26

The call incident approach for narrative writing emphasizes all of the following, EXCEPT:

A) how the incident occurred.
B) absolute chronological order.
C) surrounding circumstances.
D) mechanism of injury.

Question 27

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.

Question 28

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

A) proper acronyms.
B) approved abbreviations.
C) addenda from supervisors.
D) proper spelling.

Question 29

Writing false or malicious words intended to damage a person's character is called:

A) character assassination.
B) bad faith.
C) slander.
D) libel.

Question 30

What is the chief complaint in the following narrative? The pt. stated he had chest pain x 2 days before calling EMS. Pt. denies SOB. Vitals: BP 90/50, respirations labored with retractions, HR 44. Rx: O2 and atropine 0.5 mg IVP. Upon arrival, the pt. reported feeling better.

A) Chest pain
B) Hypotension
C) Labored respirations
D) Shortness of breath

Question 31

Instead of using the words heart attack, the paramedic could use the abbreviation:

A) AMI.
B) CP.
C) AHA.
D) HA.

Question 32

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.

Question 33

Which words are spelled incorrectly in the following narrative? Pt. is a 53 y/o male with pain to the upper thoracks and neck 2- to past history. Pt. has a history of a heart attack and takes KCl, HCTZ, and aspirin.
1) Thoracks
2) Heart attack
3) Aspirin
4) History

A) 1 only
B) 1 and 3 only
C) 3 only
D) None of the above

Question 34

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

Question 35

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

Question 36

"The 45-year-old patient had CP and was complaining of leg and arm pains." In this example, the abbreviation CP stands for:

A) cerebral palsy.
B) cerebral perfusion.
C) chest pain.
D) unable to determine.

Question 37

In filling out your prehospital care report, you want to document that your patient had a laceration to his right hand secondary to a fall. How would you abbreviate "secondary to?"

A) 2°
B) 2/
C) 2@
D) 2nd

Question 38

Which of the following situations poses an even greater risk of liability to the paramedic than patient refusal of care?

A) Denying transport to an apparently stable patient who insists he needs an ambulance
B) Transporting minors, with or without their consent
C) Transporting a mentally incompetent individual against his wishes
D) Having the patient who wants to refuse speak directly with a medical control physician

Question 39

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

Question 40

All of the following are part of the standard patient documentation narrative, EXCEPT a(n):

A) assessment/management plan.
B) subjective narrative.
C) financial assessment.
D) objective narrative.

Question 41

Which of the following statements is inappropriate for a prehospital care report?

A) The patient had trouble walking.
B) The patient's appearance indicated a lack of self-care.
C) The patient was intoxicated.
D) The patient stated, "I feel fine."

Question 42

Why is it important for billing companies to have complete PCRs?

A) They can decide what to bill for.
B) They require all information for accurate billing.
C) They provide quality assurance audits as part of their service.
D) They are required by law to collect the complete PCR.

Question 43

Why should the PCR be completed immediately after the call?

A) The medical control physician must sign it.
B) You must get back in service.
C) The information is fresh in your mind.
D) The receiving facility demands it.

Question 44

The objective narrative portion of documentation contains information on the:

A) history of the present illness.
B) current health status.
C) chief complaint.
D) physical exam.

Question 45

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

A) medical
B) administrative
C) patient care
D) legal

Question 46

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

A) CHART.
B) OPRST.
C) SAMPLE.
D) DCHART-E.

Question 47

The standard charting abbreviation for nitroglycerin is:

A) NTG.
B) NGT.
C) Nitro.
D) N₂O.

Question 48

To correct an error on the PCR, the paramedic should:

A) make it a habit to use erasable ink so mistakes can be completely erased.
B) cross it out with one line and initial it.
C) block it out completely.
D) use correction fluid matching the paper color of each copy of the PCR.

Question 49

Which of the following is the paramedic's interpretation of the patient's problem?

A) Chief complaint
B) Subjective opinion
C) Patient complaints
D) Field diagnosis

Question 50

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

A) Belly
B) Thorax
C) Jawbone
D) Chest

Question 51

Careful, thorough documentation has the effect of ________ frivolous lawsuits.

A) eliminating
B) defeating
C) discouraging
D) encouraging

Question 52

What is the patient's heart rate in the following narrative? The pt. complained of CP x 2 days before calling EMS and is now also c/o SOB. Vitals BP 90/50, labored with retractions. Treated with O₂ and atropine. Upon arrival, the pt. reported feeling better.

A) 50
B) 90
C) 40
D) Cannot be determined

Question 53

Seeking and recording pertinent negatives demonstrates which of the following?

A) Charting by exception
B) Thoroughness of your examination
C) Thoughtfulness of your care
D) Use of the PERT-NEG format

Question 54

Why do patient refusals warrant more thorough documentation than typical EMS calls?

A) Additional witnesses must be quoted.
B) The patient is usually not competent.
C) There is more time available before the next assignment.
D) The potential for abandonment charges is greater.

Question 55

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

A) law enforcement officials, in specific situations.
B) third-party billing companies.
C) medical professionals providing continuing care.
D) other paramedics not on the call.

Question 56

Which of the following best describes why abbreviations and acronyms can cause confusion and problems?

A) They are not universally accepted by all EMS agencies.
B) Nursing uses a different set of abbreviations and acronyms.
C) Some abbreviations and acronyms can have multiple meanings.
D) Physicians use a different set of abbreviations and acronyms.

Question 57

The unofficial language used by a particular group or profession is known as ________ and can be confusing when included on a PCR.

A) terminology
B) semantics
C) slang
D) jargon

Question 58

The ultimate responsibility for documentation belongs to the:

A) agency's administration.
B) paramedic writing the PCR.
C) medical control physician.
D) receiving nurse.

Question 59

Who would be held MOST responsible if poor prehospital documentation results in inappropriate continuing medical care?

A) The patient, if he was uncooperative
B) The paramedic who wrote the document
C) The paramedic agency and its medical director
D) The physician who ordered the continuing medical care

Question 60

Under what circumstances should paramedics try to hide charting errors?

A) Always
B) When directed to by a supervisor or superior officer
C) When a lawsuit is probable
D) Never

Question 61

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

A) the dispatch log.
B) your immediate recollection of events.
C) a complete and accurate PCR.
D) your partner's corroborating testimony.

Question 62

Patient and bystander quotes belong in the ________ section.

A) objective narrative
B) subjective narrative
C) assessment/management plan
D) quotation

Question 63

The standard charting abbreviation for Tylenol is:

A) ASA.
B) Acet.
C) APAP.
D) Amp.

Question 64

Your patient is complaining of respiratory distress. In ruling out congestive heart failure, the absence of swollen ankles would be a:

A) false positive finding.
B) false negative finding.
C) pertinent negative finding.
D) true positive finding.

Question 65

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

A) patient's identifying information.
B) vital signs.
C) paramedics' names.
D) treatments rendered.