chapter 6

The accuracy of your patient care report depends on all of the following factors, EXCEPT: Including all pertinent event times. documenting any extenuating circumstances the thoroughness of the narrative section the severity of the patient's condition

The severity of the patient's condition. pages 181-182

Which of the following would be considered objective data? -opinion of what caused the MOI/NOI -condition of the pt home -pt chief complaint -pt description of his pain

condition of the pt home

you are on scene at a car- pedestrian accident and the pedestrian refuses medical attention, even though he is clearly injured. What should you do? - Have law enforcement take the patient into protective custody -obtain and document vitals even though the pt objects -leave the pt alone-he has a right to refuse treatment - contact medical control

contact medical control

Most EMS agencies require a double signature system any time a:

controlled substance is checked, used, discarded, or replaced. page 179

If you make an error when completing a written patient care report, you should:

use different colored ink when drawing a single line through the error. page 184

All of the following are subjective findings, EXCEPT: a feeling of impending doom acute and severe nausea visible blood in the ear canal a persistent dull headache

visible blood in the ear canal. Page 170

________ is a false verbal statement that injures a person's reputation.

Slander

Which of the following statements is LEAST descriptive when documenting the events of a cardiac arrest call on your patient care report? "Gave 1 mg of epinephrine at 1002." "Followed ACLS protocols." "Intubated with a 7.5-mm ET tube." "Inserted 18-gauge IV in the right forearm."

"Followed ACLS protocols." page 179

Which of the following statements contains objective and subjective information? "the pt appeared confused and stated that he had a headache" "the pt pulse was rapid and weak and he was diaphoretic" "the pt wife stated that he began feeling ill a few hours ago" "the pt behavior was consistent with alcohol intoxication"

"the patient appeared confused and stated that he had a headache" page 170

PCRs may be used as all of the following EXCEPT: -a pt description for the media -legal documents -quality assurance reviews -billing documents

A patient description for the media. page 171-172

Each of the following is a method used to organize the narrative section of the PCR, EXCEPT: -body systems/parts approach -AVPU -SOAP method -CHARTE method

AVPU. page 179

In most states, the paramedic is required to provide a supplemental report, aside from the PCR, in the case of a: -pt injured in a car crash -cardiac arrest pt -child who was abused -burn patient

Child who was abused. page 178-179

Which of the following documentation styles would likely be MOST difficult and time consuming to apply in EMS?

Body systems approach

Which of the following constitutes minimum data that must be included on every patient care report?

Chief complaint, level of consciousness, vital signs, assessment, and patient's age and gender. page 173

If a patient with decision-making capacity adamantly refuses treatment for an injury or condition that clearly requires immediate medical attention, the paramedic should:

Contact online medical control for guidance

In which of the following situations would the documentation on a patient care report MOST likely be limited?

Mass-casualty incident. page 175

Which of the following laws or entities requires that a statement of medical necessity be clearly documented on a patient care report?

Medicare

After you completed and submitted your electronic report, supplemental information becomes available. Which of the following actions would be the MOST appropriate to take? -Notify the appropriate supervisor of the error and complete a supplemental report -reopen your electronic report and add the information with out notifying anyone of the change -notify the appropriate supervisor of the mistake and ask him/her to make a change to the report -Do nothing, because the report has already been submitted

Notify the appropriate supervisor of the error and complete a supplemental report.

Which of the following statements regarding revisions or corrections to a patient care report is correct?

Only the person who wrote the original report can revise or correct it.

When documenting a statement made by the patient or others at the scene, you should:

Place the exact statement in quotation marks in the narrative.

Which of the following is NOT a reason for completing a PCR? -Protection from litigation -Research -Billing -Continuity of care

Protection from litigation

Different EMS systems might use a variety of report-writing formats. Which of the following is an example of a report-writing format? -HEARSAY -TALK -SOAP -SAMPLE

SOAP. page 179

You are treating a patient who sustained a head injury. He describes the pain as radiating from his right ear down his neck. This is an example of what type of information:

Subjective information

What information do you gather when you're using the SOAP Method?

Subjective information, objective information, assessment, plan

During a MCI, who completes the PCR on each patient? -the EMS provider on scene -the ambulance crew -the medical control officer -the ER

The ambulance crew

In which of the following situations would a medical necessity for ambulance transport MOST likely be required?

The patient required a splint prior to moving.

What should occur if a physician on scene performs an intervention that is outside of the paramedic's scope of practice?

The physician is required to accompany the patient in the back of the ambulance.

Patients may have the ability and right to refuse medical care. Which of the following patients would have an appropriate case for refusing care? -10 y/o boy who was injured in skateboarding crash -28 y/o woman who fell off a barstool and struck her head -19 y/o woman who is conscious and alert -70 y/o man who called for assistance and was found shivering in an unheated house

a 19 y/o woman who is conscious and alert. page 174-175

pt data include the basic pt information collected on a PCR, which documents such information as the chief complaint and the: -call location -assessment findings -arrival time at the hospital -disposition hospital

assessment findings. page 173

Data collected from the state EMS office for the purpose of research would likely NOT include:

average cost per call. page 171-172

If you receive another call before completing the patient care report accurately for the previous call:

pertinent details about the previous call may be omitted inadvertently.

In your PCR, you write " Patient denies any shortness of breath with her chest pain, and denies any radiation of chest pain to other parts of the body." This is an example of a _________. -pertinent negative -minimum data set -refusal of care -body systems approach

pertinent negative

If the paramedic is unable to complete his or her patient care report before departing the emergency department, he or she should:

leave an abbreviated form with pertinent data with the receiving provider and complete the patient care report as soon as possible. page 182

For purposes of refusing medical care, a patient's mental status may be considered impaired if he or she:

makes nonsensical statements. page 175

A poorly written patient care report:

may raise questions by others as to the paramedic's quality of patient care. Page 183-184

Documentation of the chief complaint, vital signs, level of consciousness, patient demographics and assessment information is referred to as the ______?

minimum data set

Proper documentation is an essential job function of a paramedic. Today, in the majority of the jurisdictions in the United States, this formal written report is referred to as a: -trip sheet -patient care report -call sheet -contact file

patient care report. page 170

Which of the following data would a state EMS office be the LEAST likely to require an EMS agency to report? patient gender patient outcome types of calls call volume

patient gender. pages 171-172

HIPAA requires that:

patient information shall not be shared with entities or persons not involved in the care of the patient.

The patient care report:

provides for a continuum of patient care upon arrival at the hospital.

Which of the following would NOT be an example of a significant finding that indicates medical necessity for ambulance reporting? -Pt is transported in an emergency mode per standard operating procedure -pt needs to be chemically and physically restrained -pt has no other means of transport for his doctor's appointment -pt has uncontrollable hemorrhage

pt has no other means of transport. page 171

An accurate and legible patient care report:

should be complete to the point where anyone who reads it understands exactly what transpired on the call. Page 185

Which of the following incident times is NOT commonly documented on the patient care report? time of departure from the scene time of medication administration time of arrival at the hospital time of primary assessment

time of primary assessment. page 185-186

A thorough pt refusal should involve documentation on the PCR of each of the following, EXCEPT: -your opinion that the pt is a system abuser. -the willingness of the EMS to return -evidence that the patient is able to make rational, informed decisions -discussion with medical control according to protocols

your opinion that the pt is a system abuser. page 178