EMT Chapter 4 Communications and Documentation

A patient's refusal for EMS treatment and/or transport must be: Select one: A. authorized by a judge. B. witnessed by a notary. C. reported to the police. D. an informed refusal.

an informed refusal.

A ___________ receives messages and signals on one frequency and then automatically retransmits them on a second frequency. Select one: A. scanner B. duplex C. decoder D. repeater

repeater

Typical components of an oral patient report include all of the following, EXCEPT: Select one: A. the chief complaint or mechanism of injury. B. the patient's response to treatment you provided. C. the set of baseline vital signs taken at the scene. D. important medical history not previously given.

the set of baseline vital signs taken at the scene.

A 60-year-old man complains of chest pain. He is conscious and alert and denies shortness of breath. Which of the following questions would be the MOST appropriate to ask him? Select one: A. "Does the pain in your chest feel like a stabbing sensation?" B. "Were you exerting yourself when the chest pain began?" C. "Do you have any heart problems or take any medications?" D. "Does the pain in your chest move to either of your arms?"

"Do you have any heart problems or take any medications?"

Which of the following statements is NOT appropriate to document in the narrative section of a PCR? Select one: A. "General impression revealed that the patient was intoxicated." B. "The patient admits to smoking marijuana earlier in the day." C. "After oxygen was administered, the patient's breathing improved." D. "Significant damage was noted to the front end of the vehicle."

"General impression revealed that the patient was intoxicated."

Which of the following statements regarding a patient refusal is MOST correct? Select one: A. Advice given to a patient who refuses EMS treatment should not be documented. B. A patient who consumed a few beers will likely be able to refuse EMS treatment. C. A mentally competent adult has the legal right to refuse EMS care and transport. D. Documentation of proposed care is unnecessary if the patient refuses treatment.

A mentally competent adult has the legal right to refuse EMS care and transport.

You are interviewing a 52-year-old man who complains of chest discomfort. The patient is a retired paramedic and is very anxious because he thinks he is having a heart attack. Which of the following statements would be appropriate to say? Select one: A. "I notice that you are a retired paramedic, so I'm sure you will understand all of the things that we will be doing to you." B. "It is possible that you are experiencing a heart attack. I am going to give you four baby aspirin to chew and swallow." C. "We need to take you to the ED stat. We will give you ASA and NTG en route and then reassess your vitals. Do you have any questions?" D. "This is nothing to worry about. Please try to stay calm. The physician at the hospital will probably not find any signs of a heart problem."

B

A 4-year-old boy had an apparent seizure. He is conscious and calm and is sitting on his mother's lap. His father is sitting in a nearby chair. The child's mother suddenly begins crying uncontrollably, which causes the child to start crying. You should: Select one: A. attempt to calm the child's mother, but avoid separating her from her child because this will increase her anxiety. B. give the child a favorite toy or blanket to hold onto and perform your assessment to the best of your ability. C. consider asking the father to hold the child so you can assess him while your partner tries to calm the mother. D. reassure the child's mother that seizures in children are very common and that there is nothing to worry about.

C

After delivering your patient to the hospital, you sit down to complete the PCR. When documenting the patient's last blood pressure reading, you inadvertently write 120/60 instead of 130/70. To correct this mistake, you should: Select one: A. leave the error on your PCR but inform the staff of the patient's actual blood pressure. B. attempt to erase the error, initial it, and then write the correct data on a separate addendum. C. draw a single horizontal line through the error, initial it, and write the correct data next to it. D. cover the error with correction fluid and simply write the patient's actual blood pressure over it.

C

You are assessing a 75-year-old woman with mild shortness of breath. As you are asking her questions regarding her chief complaint and medical history, you progressively move closer and closer to her. In doing this, it is important to remember that: Select one: A. it is necessary to enter an older person's intimate space because the elderly are typically hearing impaired. B. a patient's personal space should not be violated, regardless of any barriers that may hamper communication. C. as you physically get closer to the patient, a greater and greater sense of trust must be established. D. placing yourself in the patient's personal space is relaying to her that you can be trusted.

C

You and your partner are dispatched to a residence for an "ill person." When you arrive, you find that the patient, a 44-year-old man, does not speak English. There are no relatives or bystanders present who can act as an interpreter. You should: Select one: A. speak to the patient with a moderately louder voice to facilitate his ability to understand what you are saying. B. refrain from performing any assessment or treatment until you can contact someone who can function as an interpreter. C. give the patient oxygen, assess his vital signs, and transport him to the hospital in a position of comfort. D. use short, simple questions and point to specific parts of your body to try to determine the source of the patient's complaint.

D

You are dispatched to the residence of an Asian family for a child with a high fever. When you assess the child, you note that he has numerous red marks on his back. The child's parents explain that these marks represent coining—a traditional Asian healing practice in which hot coins are rubbed on the back. You should: Select one: A. advise the emergency department physician that you feel as though the child was intentionally abused by his parents. B. acknowledge and respect this practice as a cultural belief, but advise the child's parents that it has no healing power. C. advise the child's parents that this is a harmful practice and is considered a form of child abuse in the United States. D. document this on your patient care report and advise the emergency department staff of what the child's parents told you.

D

Your EMS system uses a computerized PCR in which you fill in the information electronically and then send it to the emergency department via a secure Internet server. The PCR has a comprehensive series of drop-down boxes, which are used to identify your assessment findings and specify the treatment that you provided; it also has a section for your narrative. When completing your PCR after a call, you should: Select one: A. defer the narrative only if the information in the drop-down boxes accurately reflects the assessment and treatment that you performed. B. avoid documenting personally identifiable information, such as the patient's name, because the PCR could be intercepted during transmission. C. enter all of the pertinent information of the electronic PCR, but then print it out and provide a copy to the emergency department staff. D. complete a thorough and accurate narrative because drop-down boxes cannot provide all of the information that needs to be documented.

D

You and your partner are attempting to resuscitate a middle-aged female in cardiac arrest. Because of the remote location you are in, you are unable to contact medical control. What should you do? Select one: A. Make continuous attempts to contact medical control. B. Perform CPR only and initiate immediate transport. C. Ask the husband if he wants to continue resuscitation. D. Follow locally established protocols or standing orders.

Follow locally established protocols or standing orders.

You are transporting a 54-year-old male in cardiac arrest. An EMR is driving the ambulance as you and your partner attempt to resuscitate the patient. What is the MOST logical way of notifying the hospital? Select one: A. Have the driver contact dispatch and relay the patient information to the hospital. B. Wait until you arrive at the hospital and then quickly apprise them of the situation. C. Call the receiving hospital with your cellular phone as you attempt resuscitation. D. Request that a police officer respond to the hospital to apprise them of your arrival.

Have the driver contact dispatch and relay the patient information to the hospital.

Which of the following statements regarding a "dedicated line" is MOST correct? Select one: A. It is a constantly open line of communication that is under exclusive control of a single user. B. It is a designated frequency on a portable radio that provides direct access to medical control. C. It is an exclusive frequency that is used by EMTs to communicate with each other in the field. D. It is a constantly open line of communication that cannot be accessed by outside users.

It is a constantly open line of communication that cannot be accessed by outside users.

Which of the following statements regarding standing orders is MOST correct? Select one: A. Standing orders only highlight the care that you may provide. B. Standing orders should be followed when physician contact is not possible. C. Standing orders require you to contact medical control first. D. Standing orders have less legal authority than orders given via radio.

Standing orders should be followed when physician contact is not possible.

Which of the following statements regarding communication with a child is MOST correct? Select one: A. Most children are intrigued by strangers wearing uniforms. B. Standing over a child often increases his or her level of anxiety. C. Give the child minimal information to avoid scaring him or her. D. Unlike adults, children cannot see through lies or deceptions.

Standing over a child often increases his or her level of anxiety.

Information included in a radio report to the receiving hospital should include all of the following, EXCEPT: Select one: A. a brief summary of the care you provided. B. a brief history of the patient's current problem. C. your perception of the severity of the problem. D. a preliminary diagnosis of the patient's problem.

a preliminary diagnosis of the patient's problem.

Medical control gives you an order that seems inappropriate for the patient's condition. After confirming that you heard the physician correctly, you should: Select one: A. carry out the order and then carefully document it on the run form. B. obtain consent from the patient and then carry out the order as usual. C. advise the physician that the order is unclear and ask for clarification. D. state that you will not carry out the order because it is inappropriate.

advise the physician that the order is unclear and ask for clarification.

During your assessment of a 20-year-old man with a severe headache and nausea, you ask him when his headache began, but he does not answer your question immediately. You should: Select one: A. ask him if he frequently experiences severe headaches and nausea. B. tell him that you cannot help him unless he answers your questions. C. allow him time to think about the question and respond to it. D. repeat your question because he probably did not hear you.

allow him time to think about the question and respond to it.

Despite numerous, sincere efforts to convince a 40-year-old man to consent to EMS treatment and transport, he refuses. After explaining the potential consequences of his refusal and determining that he has decision-making capacity, you ask him to sign an EMS refusal form, but he refuses to do that as well. You should: Select one: A. document the patient's refusal, but leave the refusal form blank because only the patient can legally sign it. B. advise the patient that unless he signs the refusal form, he cannot legally refuse EMS treatment or transport. C. ask a family member, law enforcement officer, or bystander to sign the form verifying that the patient refused to sign. D. sign the refusal form, include the date and time, and have your partner witness it with his or her signature.

ask a family member, law enforcement officer, or bystander to sign the form verifying that the patient refused to sign.

Any radio hardware containing a transmitter and receiver that is located in a fixed location is called a: Select one: A. mobile radio. B. repeater. C. multiplex. D. base station.

base station.

When relaying patient information via radio, communications should be: Select one: A. spoken in a loud voice. B. coded and scripted. C. lengthy and complete. D. brief and easily understood.

brief and easily understood.

In what manner should you act and speak with a patient? Select one: A. loud and official B. passive C. calm and confident D. authoritative

calm and confident

Which of the following incidents does NOT require a report to be filed with local authorities? Select one: A. gunshot wounds B. cardiac arrest C. spousal abuse D. animal bites

cardiac arrest

When you begin an oral report, you should state the patient's age, sex, and: Select one: A. the emergency care given. B. any known allergies. C. past medical history. D. chief complaint.

chief complaint.

Immediately after being dispatched to a residence for an elderly patient with diabetic complications, you should: Select one: A. confirm with dispatch that you received the call information. B. ask the dispatcher to obtain a medical history from the caller. C. request that law enforcement secure the scene before you arrive. D. ask the dispatcher if the patient is conscious or unconscious.

confirm with dispatch that you received the call information.

All information recorded on the PCR must be: Select one: A. typewritten or printed. B. reflective of your opinion. C. a matter of public record. D. considered confidential.

considered confidential.

Ethnocentrism is defined as: Select one: A. suspecting that a person has an ulterior motive based on the tone of his or her voice when answering a question. B. considering your own cultural values as more important when interacting with people of a different culture. C. understanding that people from different cultural backgrounds respond to pain and stress differently. D. subconsciously forcing your cultural values onto a patient because you feel that yours are more acceptable.

considering your own cultural values as more important when interacting with people of a different culture.

The patient care report (PCR) ensures: Select one: A. legal protection. B. continuity of care. C. research data. D. quality assurance.

continuity of care.

When communicating with a visually impaired patient, you should: Select one: A. determine the degree of the patient's impairment. B. recall that most visually impaired patients are blind. C. expect him or her to have difficulty understanding. D. possess an in-depth knowledge of sign language.

determine the degree of the patient's impairment.

During the alert and dispatch phase of EMS communications, the dispatcher's responsibilities include all of the following, EXCEPT: Select one: A. selecting and notifying the correct EMS response units and personnel. B. discouraging the caller from providing care until the EMS unit arrives. C. coordinating responding EMS units with other public safety personnel. D. screening and assigning a priority to each call based on local protocols.

discouraging the caller from providing care until the EMS unit arrives.

Communicating with hearing-impaired patients can be facilitated by doing all of the following, EXCEPT: Select one: A. placing yourself in a position to ensure that the patient can see your lips. B. elevating the tone of your voice and exaggerating word pronunciation. C. providing pen and paper if the patient prefers to write his or her response. D. shining a light on your face when you are in a darkened environment.

elevating the tone of your voice and exaggerating word pronunciation.

The official transfer of patient care does not occur until the EMT: Select one: A. notifies the admitting clerk of their arrival at the hospital. B. gives a radio report to the receiving medical facility. C. informs dispatch of their arrival at the emergency department. D. gives an oral report to the emergency room physician or nurse.

gives an oral report to the emergency room physician or nurse.

Which of the following has the weakest transmission signal and, as a result, is LEAST likely to be heard by the party being called? Select one: A. multiplex base station B. hand-held portable radio C. mobile repeater station D. land-base repeater station

hand-held portable radio

When obtaining patient care orders from a physician via a two-way radio, it is MOST important to remember that: Select one: A. all orders should be carried out immediately and without question. B. his or her instructions are based on the information you provide. C. the use of 10 codes is an effective method of communication. D. the physician may or may not be located within your service area.

his or her instructions are based on the information you provide.

Which of the following is NOT a function of the Federal Communications Commission (FCC)? Select one: A. licensing base stations and assigning appropriate radio call signs B. monitoring all radio traffic and conducting field spot checks C. maintaining communications equipment on the ambulance D. allocating specific radio frequencies for use by EMS providers

maintaining communications equipment on the ambulance

Calming and reassuring an anxious patient can be facilitated by: Select one: A. positioning yourself at a level that is higher than the patient. B. maintaining eye contact with the patient whenever possible. C. withholding unpleasant information until arrival at the hospital. D. using medical terminology to ensure the patient understands.

maintaining eye contact with the patient whenever possible.

When communicating with an older patient, it is important to remember that: Select one: A. most older people think clearly and are capable of answering questions. B. your questions should focus exclusively on the patient's obvious problem. C. speaking loudly and distinctly will ensure that the patient can hear you. D. hostility and confusion should be presumed to be due to the patient's age.

most older people think clearly and are capable of answering questions.

When providing a patient report via radio, you should protect the patient's privacy by: Select one: A. withholding medical history data. B. not disclosing his or her name. C. refraining from objective statements. D. using coded medical language.

not disclosing his or her name.

After receiving online orders from medical control to perform a patient care intervention, you should: Select one: A. repeat the order to medical control word for word. B. confirm the order in your own words. C. ask the physician to repeat the order. D. perform the intervention as ordered.

repeat the order to medical control word for word.

As you are wheeling your patient through the emergency department doors, you receive another call for a major motor vehicle crash. You should: Select one: A. inform the admissions clerk of the situation and then respond at once. B. respond only after giving a verbal patient report to a nurse or physician. C. place the patient in a high-visibility area and then respond to the call. D. leave a copy of the run form with a nurse and then respond to the call.

respond only after giving a verbal patient report to a nurse or physician.

What type of communications equipment functions as a radio receiver and searches across several frequencies? Select one: A. scanner B. simplex station C. mobile repeater D. duplex station

scanner

Two-way communication that requires the EMT to "push to talk" and "release to listen" describes what mode of communication? Select one: A. mediplex B. simplex C. multiplex D. duplex

simplex

You could be sued for ___________ if your radio report to the hospital describes the patient in a manner that injures his or her reputation. Select one: A. assault B. negligence C. slander D. libel

slander

After being dispatched on an emergency call, you should expect the dispatcher to provide you with all of the following information, EXCEPT: Select one: A. the number of patients involved in the incident. B. the time at which your unit was dispatched. C. other agencies that are responding to the scene. D. the general geographic location of the incident.

the general geographic location of the incident.

While at the scene of a motor vehicle crash, you determine that there are two critically injured patients and that another ambulance is needed. You attempt to contact the dispatcher with your portable radio but are unsuccessful. You should: Select one: A. ask a police officer to call dispatch with his portable radio. B. use the mobile radio in the ambulance to contact dispatch. C. place both patients in the ambulance and transport at once. D. reattempt to contact dispatch from an area of higher terrain.

use the mobile radio in the ambulance to contact dispatch.

When communicating information over the radio, you should: Select one: A. respond professionally by saying "please" and "thank you." B. use the words "affirmative" and "negative" instead of "yes" or "no." C. limit any single transmission to 60 seconds or less and use 10 codes. D. use the patient's name only when communicating with the hospital.

use the words "affirmative" and "negative" instead of "yes" or "no."

General guidelines for effective radio communications include all of the following, EXCEPT: Select one: A. acknowledging a transmission as soon as possible. B. using 10 codes to ensure radio traffic confidentiality. C. holding the microphone about 2" to 3" from your mouth. D. speaking in a clear, calm, monotone voice.

using 10 codes to ensure radio traffic confidentiality.