Chapter 15, Communication and Documentation

12

How many parts does a standard medical radio report have as described in your textbook?

Ambulance mobile radio

A major tornado has hit the neighboring town, knocking down power lines and injuring several people. What will provide the best chance to give your patient report to the receiving facility?

Biased

An objective statement made in a prehospital patient care report meets all of the follwoing criteria except which one? biased measurable verifiable observable

Multiple patients come from an office building evacuation

In which of the following circumstances is a fully documented patient care report NOT necessary? multiple patients come from an office building evacuation a patient is treated but not transported a patient says that someone else called EMS and he does not want any assistance a fully documented patient care report is required for all of the above

The fact that the EMT had an exposure incident

Two EMT's are on scene of a behavioral call at a psychiatric facility. The medical personnel state that the patient had a psychotic episode and slashed his wrists. During the call, the patient claims to hear the voice of God and says that the voice is hurting his ears. The patient refuses to be transported to the emergency department, becomes combative, and bites one of the EMTs. Which of the following should NOT be documented on the EMS report? the fact that the patient hears voices the fact that the EMT had an exposure incident The fact that the patient slashed his wrists The fact that the patient was violent and bit the EMT

The nurse may have to perform critical interventions on the patient before you complete your written report.

When you arrive at the receiving facility, the nurse asks your partner for a verbal report of the patient's conditional. This is in addition to the radio report your partner gave to the hospital en route. Afterwards, you ask your partner why you must give a second verbal report and a written report to the receiving nurse. What is the best reason to provide both reports

A two way radio that is mounted in a vehicle

Which of the following BEST describes a mobile radio?

Federal Communications Commission

Which of the following agencies assigns and licenses radio frequencies?

The patient stated that she felt sick

Which of the following can be correctly noted as a chief complaint?

Patient's atitude

Which of the following in NOT appropriate to document on you r patient care report? patients attitude patients mental status patients race all should be documented

Estimated time of arrival at the hospital

Which of the following information does NOT need to be provided to the dispatcher?

Chief complaint

Which of the following information on a patient care report is NOT considered run date? Time of arrival at the receiving facility other EMS units on the scene location of the call chief complaint

Satisfy requirements of the shift supervisor

Which of the following is NOT a reason for routine review of patient care reports in a quality improvement program?

Avoid communicating with the patient so there is no misunderstanding of your intentions

Which of the following is NOT an appropriate way of dealing with a patient who does not speak the same language as you do? avoid communicating with the patient so there is no misunderstanding of your intentions. contact dispatch for assistance in finding a translator use an interpreter use a manual that provides translation

All of the above

Which of the following is a possible consequence of using medical terminology about which you are unsure of the meaning in your patient care report? Embarrassment Negative impact on patient care loss of credibility all of the above

Time of arrival at the patient's location

Which of the following is part of the minimum data set developed by the National Highway Traffic Safety Administration (NHTSA) for purposes of data collection in conducting research?

Draw a single line through the error and initial it.

Which of the following is the correct manner for making a correction on a patient care report?

Radio Codes

Which of the following should NOT be included in a patient care report?

Symptoms

Which of the following should be documented as subjective patient information?

Chief complaint

Which of the following should be placed in quotes in the patient care report? Chief complaint Patient's expressed consent Mechanism of injury List of patient's medications

Eye contact is always appropriate

Which of the following statements regarding eye contact with a patient is NOT true?

You should document everything including all patient care, all of your attempts to persuade the patient to go by ambulance, and who witnessed the patient refusal

You are on a call of a minor vehicle accident. your patient is a 22 ear old male who was the driver of a moderate T-bone collision. The patient was not wearing a seat belt and there was spidering of the windshield. The patient complains of neck pain and has a scalp laceration. After performing the primary assessment, you take vital signs and bandage the patient's scalp. When you tell him you need to backboard him, he refuses care and ambulance transport. Because the person is alert and oriented to time, place, and person, you have the patient sign the separate patient refusal form provided by your service. How should you document this incident in your EMS report?

"I will do my best, but it may hurt while we put the splint on."

You are treating a patient with a possible fractured ankle. The patient appears to be in a lot of pain and is uneasy. As you are getting ready to splint the patient's leg, he asks you if it is going to hurt. Which of the following is the BEST response?

Listen to the frequency first to avoid stepping on another transmission

You have an urgent transmission you need to make to the dispatch center. Which of the following is the appropriate way to communicate this? listen to the frequency first to avoid stepping on another transmission interrupt less urgent radio traffic to get your message across Use the phrase, "attention, attention, I have priority traffic." speak loudly to convey the urgency of the message

State that you are unable to comply with the request due to patient confidentiality

You have responded to a call at a government office building,. One of the office workers became very upset during a fire drill and experienced an episode of difficulty breathing. As your partner is speaking with the patient, who is not sure she wants to be transported, an individual wearing civilian clothes approaches you and states she is a security guard in the building. She asks you for the "yellow copy" of your patient care report. Which of the following should you do?

Document any pertinent information that was said by the stepmother and child exactly in the patient report?

You suspect that a 6 year old female patient with multiple bruises and a broken wrist was abused. The stepmother states the patient fell sown the stairs. The patient is crying and sheepishly nods in agreement with the stepmother's statements. How should you document this situation in the patient report? document any pertinent information that was said by the stepmother and child exactly in quotations. document only the actual exam findings. Do not document anything that was said document who you suspect caused the injuries in the narrative so law enforcement has a record of the incident document what was said as well as your opinion that the child was too afraid to tell the truth