EMT Chapter 4

When getting a refusal from a patient who does not want the services of EMS​ providers, it is critical for the EMT to complete which​ step? A. Make sure that the hospital is notified B. Have the patient sign and date the refusal form C. Make sure the patient has another way to get to the hospital D. Make sure that the patient is younger than 65 years

Have the patient sign and date the refusal form

TIA is a commonly accepted abbreviation​ for: A. Transported in ambulance. B. Telephoned in advance. C. Transient ischemic attack. D. Tube in airway.

Transient ischemic attack.

What is the MOST widely used format for creating patient care reports in​ EMS? A. Smartphone PCR application format B. Paper PCR format C. ​Computer-based PCR format D. Electronic clipboard PCR format

​Computer-based PCR format An alternative format to the written report that is widely accepted and most commonly used is the computerized direct data entry report that is completed on a mobile computer. The styles of computerized direct data entry reports may vary. The electronic clipboard and smartphone application are types of​ electronic-based PCR​ formats, but they are not used as widely as​ computer-based PCR formats.

You document the following on the prehospital care​ report: "c/o​ H/A with associated​ n/v; pt. denies existing CNS problems or history of the​ same; states positive history of AAA and ETOH​ abuse." Regarding this​ narrative, which interpretation would be most​ accurate? A. The patient has a headache B. The patient has a history of illegal drug use C. The patient is nauseated but not vomiting D. The patient has a history of migraines

The patient has a headache

What is a primary difference in the type of information found in the administrative section and in the patient information section of the​ PCR? A. The patient information includes the​ patient's address​ only, and the administrative section includes the trip times. B. The patient information includes specific assessment​ findings, and the administrative information includes the trip times. C. The patient information includes the chief​ complaint, and the administrative information includes the EMS arrival time. D. The patient information includes the patient assessment​ information, and the administrative section includes the name and address of the EMS system.

The patient information includes specific assessment​ findings, and the administrative information includes the trip times. The patient information includes specific but comprehensive patient assessment​ information, whereas the administrative information includes the times that were pertinent to the EMS call itself​ (report time, arrival​ time, departure for hospital​ time, arrival at hospital​ time, etc.). Information about the​ patient's address is found in the demographic area.

Which of the following situations would be most likely to require that the EMT provide additional documentation beyond the traditional​ PCR? A. The patient was abused or neglected. B. The patient did not need EMS. C. The patient died en route to the hospital. D. The patient was a child.

The patient was abused or neglected.

While moving a​ 67-year-old male who complains of dizziness from his residence on the​ stretcher, you stumble backward and knock a vase from a​ table, causing it to break. The patient and family are very upset with the damage. In the​ process, you hurt your ankle and are having a hard time walking. When completing the prehospital care report​ (PCR), what should be​ included? A. An objective statement about the​ family's displeasure B. The​ patient's insurance or billing information C. The fact that property damage occurred Your answer is not correct. D. A factual account of your ankle injury

The​ patient's insurance or billing information

The​ EMT's ability to accurately and completely record patient information is important not only for the continuity of​ care, but also for what other​ purpose? A. To account for all patient equipment that was used B. To ensure that the patient was treated ethically C. To demonstrate the need for upgrading to an ALS service D. To aid the quality improvement process

To aid the quality improvement process Reviews of documentation are an integral part of the quality improvement process. Remedial and continuing education courses for EMTs may be based on needs that are revealed by call documentation. PCRs are also used in medical oversight to determine whether EMTs are adhering to protocols and the set standard of care for their area. PCRs are not used to determine whether an upgrade to an ALS system is warranted. Ethical treatment refers more to interpersonal relationships and is not documented on the PCR. PCRs are not designed to be an accounting document for all equipment​ used; this is a billing issue.

A tag containing key information that is attached to a patient during a multiple-casualty incident.

triage tag

A pertinent negative would be illustrated​ by: A. ​"Hypertension and taking​ medication." B. ​"Dizziness for three days without notifying the​ doctor." C. ​"Nausea without​ vomiting." D. ​"Short of breath with history of lung​ problems."

​"Nausea without​ vomiting."

Which statement shows an accurate understanding of the legal aspects of the prehospital care report​ (PCR)? A. ​"The PCR may be subpoenaed even if the lawsuit centers on alleged negligence that occurred in the emergency​ department." B. ​"A PCR can be used in a lawsuit only if that lawsuit is filed within six​ months." C. ​"A copy of the PCR should be forwarded to the police anytime law enforcement is involved in the​ call." D. ​"The PCR is considered a legal document only when it describes a crime or act of​ violence."

​"The PCR may be subpoenaed even if the lawsuit centers on alleged negligence that occurred in the emergency​ department."

What would be considered an objective patient assessment​ finding? A. Complaint of headache for past 12 hours B. Patient rates pain as 10 out of 10 C. Blood pressure​ 114/68 mmHg D. Complaint of nausea

Blood pressure​ 114/68 mmHg

After oxygen​ therapy, the​ patient's SpO2 improves from​ 90% to​ 99%. Using the CHEATED method of​ documentation, this information would be placed in which​ category? A. ​E: Evaluation B. ​D: Disposition C. ​C: Chief complaint D. ​H: History

E: Evaluation

What is the prime reason for​ high-quality documentation? A. Legal defense B. ​High-quality patient care C. Education and research D. Billing purposes

High-quality patient care

What would be the best reason for a policy that requires all crew members to synchronize their watches with dispatch at the beginning of each​ shift? A. Promotes accurate​ system-wide time record keeping throughout the shift B. Ensures that all EMS staff are on time and ready for the shift C. Allows the supervisor to make sure that all EMTs have a watch D. Provides the best opportunity for the EMT to end the shift on time

Promotes accurate​ system-wide time record keeping throughout the shift

​"SOAP," "CHART," and​ "CHEATED" are all methods to help the EMT accomplish what​ task? A. Proper verbal communication with the receiving facility B. Proper spinal immobilization C. Proper documentation on the PCR D. Proper documentation of special reporting forms used in EMS

Proper documentation on the PCR ​SOAP, CHART, and CHEATED represent different methods to organize the information expected to be documented on the prehospital care report. Whatever system is​ developed, it is important that it is used to ensure the most accurate documentation of the patient information.

Of the following suspicions that the EMT may develop when caring for a​ patient, which is most likely to necessitate the need for the EMT to complete a special report relative to the​ patient's condition? A. That the patient was not being honest. B. That the patient might refuse care. C. A mechanical problem with his or her vehicle. D. That an elderly patient has been abused.

That an elderly patient has been abused.

What is an example of improper documentation on a patient care​ report? A. Whether the patient thought the EMS providers acted appropriately. B. Interventions and response to interventions. C. Information from the scene. D. Trends in the​ patient's condition.

Whether the patient thought the EMS providers acted appropriately. Complete documentation includes trends in the​ patient's condition, responses to​ interventions, and information from the scene. It does​ not, however, include feedback from the patient. That would be gathered by administering CQI evaluations following the trip.

A patient states that he has suffered from chronic neck pain ever since an accident.​ Further, he states that he is filing a lawsuit against the EMTs since they failed to put a cervical collar on him at the​ time; in his​ eyes, this is the reason he has daily neck and back pain. The EMT can remember the incident well and remembers putting a collar on the patient. As​ such, his best defense would​ be: A. Presentation of the standard of care showing that a cervical collar is indicated B. Written documentation of collar placement on the PCR C. Testimony from the supervisor stating that the EMTs always place a cervical collar D. Presentation of the emergency department chart in court

Written documentation of collar placement on the PCR

The minimum information the U.S. Department of Transportation has determined should be included on all prehospital care reports.

minimum data set

A​ 24-year-old man was the driver in a car crash. The skin over his collarbone is red and​ swollen, but he tells you that it​ doesn't hurt. This is best described as​ a: A. pertinent negative. B. distracting injury. C. missing complaint. D. spinal injury.

pertinent negative. In questioning a​ patient, be alert for pertinent negatives. These are signs or symptoms that might be expected on the basis of the chief complaint but that the patient denies having. A pertinent negative might be a​ patient's denial of pain after an automobile crash or a lack of difficulty in breathing in a case of chest pain. By noting the absence of pertinent signs and​ symptoms, you will provide the medical team that takes over care of the patient a fuller picture of his condition. A distracting injury is one that keeps the patient from realizing that another area of the body is injured. A spinal injury is just that​ (but not the correct​ answer), and a missing complaint is a fictitious name that is incorrect.

Signs or symptoms that might be expected in certain circumstances, based on the chief complaint or physical exam, but are denied by the patient or not found on examination.

pertinent negatives

The​ "P" in the mnemonic SOAP stands​ for: A. palliation. B. pain. C. provocation. D. plan.

plan.

Documentation of an EMT's contact with a patient.

prehospital care report (PCR)

Two days after a​ call, you realize that you forgot to document that you checked a​ patient's blood glucose prior to him refusing transport and signing the refusal form. At that​ time, you did contact medical direction and provide this information to the​ doctor, prior to him authorizing the patient to refuse. What is now your best course of​ action? A. Add an addendum to the report with the correct​ information, the current​ date, and the​ EMT's initials B. Complete a new refusal form and return to the​ patient's residence to have him sign this form C. Disregard the mistake since the patient was not transported to the hospital and medical direction was aware of the blood glucose reading D. Report the error to the State Department of Emergency Medical Services

Add an addendum to the report with the correct​ information, the current​ date, and the​ EMT's initials

Which EMS systems should be collecting the minimum data set on all emergency​ runs? A. All EMS systems B. Private EMS systems C. Third service public EMS systems D. ​Fire-based EMS systems

All EMS systems The U.S. Department of Transportation​ (USDOT) has made an effort to standardize the information collected on PCRs. Such standardization​ will, it is​ hoped, lead to a higher general level of patient care across the nation. It will also permit more meaningful comparison and analysis of data from various​ systems, which may speed the implementation of new and better methods of emergency care. As​ such, all EMS systems are expected to comply.

The medical director for your service has put you in charge of designing a new prehospital care report form. He states that it must contain the​ "minimum data​ set" as set forth by the U.S. Department of Transportation. In completing this​ task, you realize that incorporating these data into your report form​ will: A. Work toward creating a single report form for all EMS systems that handle emergency calls B. Permit easier tracking of​ motor-vehicle collisions so that hazardous roads and intersections can be identified C. Increase EMS funding received from the federal and state governments D. Allow easier comparison of specific EMS data between various types of emergency systems

Allow easier comparison of specific EMS data between various types of emergency systems

A nauseated patient with fever and abdominal pain states that he has not vomited. Which description best represents how that fact should be​ documented? A. As a treatment finding B. As a pertinent negative C. As a subjective finding D. This fact would not be documented.

As a pertinent negative

When utilizing the SOAP mnemonic for​ documentation, what does the​ "A" stand​ for? A. Actions B. Assessment C. Accidents D. Agitation

Assessment

Which patient who refuses treatment should still be transported to the​ hospital? A. A homeless man in his 50s who is dirty and disheveled and has a​ body-wide rash B. An alert and oriented​ 57-year-old male who is having chest pain and is diaphoretic C. ​16-year-old female who lives in her​ parents' house and has a child D. A​ 29-year-old female who attempted to cut her wrists earlier during a failed suicide​ attempt, but now changes her story and states it was an accident

A​ 29-year-old female who attempted to cut her wrists earlier during a failed suicide​ attempt, but now changes her story and states it was an accident

Which item would the EMT place in the administrative information section of the prehospital care​ report? A. Blue State Insurance​ #425-22892; GRP# 456298 B. ​Patient: Henry, Steven M C. BLS Unit​ 51-20; Incident​ # 67-8971-90 D. ​"Patient found supine on the​ porch."

BLS Unit​ 51-20; Incident​ # 67-8971-90

Which of the choices is the proper abbreviation for​ "cardiovascular"? A. CVX B. CRDVAS C. CRVX D. CV

CV ​"CV" is the proper medical abbreviation for the word cardiovascular.

Just before the end of their​ shift, EMTs transported a young male who bystanders state​ "passed out" and then had a seizure.​ Now, an hour​ later, the patient has been stabilized and the physician asks the nurse if she knows what the seizure looked like. To easily answer this​ question, she​ would: A. Question the patient B. Contact and question the bystanders C. Call the EMTs at home D. Check the prehospital care report

Check the prehospital care report

Which one of the following belongs in the patient narrative section of the prehospital care report​ (PCR)? A. Chief complaint B. Care given prior to arrival C. Location of the patient D. Insurance and billing information

Chief complaint

An EMT documenting the assistance to a patient for taking a medication without the approval of medical direction is an example of what type of​ error? A. Abandonment B. Commission C. Permission D. Omission

Commission An error of commission occurs when the EMT does something he should not have done. If an error of omission or commission​ occurs, the EMT should not try to cover it up on the PCR.​ Instead, the EMT should document exactly what did or did not happen and what steps​ (if any) were taken to correct the situation. False information may lead to suspension or revocation of EMT certification or license​ and, potentially, to criminal charges.​ Essentially, if you write something that is not​ true, you are falsifying the document.

Immediately after giving a prehospital care report to the nurse in the emergency​ department, dispatch informs you that there are no more ambulances available and you must immediately leave the hospital to cover another portion of the county. Since your service uses a computerized documentation system and there is no time to complete your​ report, your best course of action should be​ to: A. Complete an abbreviated​ transfer-of-care report B. Give a verbal report to the ED physician C. Repeat your assessment findings and treatment to the nurse D. Leave and return to complete the report as soon as possible

Complete an abbreviated​ transfer-of-care report

Your protocol​ reads: "O2 via NC prn if symptomatic for CP​ / SOB and SpO2​ < 94%." To follow this​ order, you should do perform which​ action? A. Call medical direction to administer oxygen if the pulse oximeter reading is greater than​ 94% B. Administer oxygen via face mask if the patient denies a complaint and has a pulse oximeter reading of​ 98% C. Consider oxygen for a patient complaining of chest pain if the SpO2 is​ 92% D. Administer oxygen through a nasal cannula at 3 liters per minute if the pulse oximeter reads​ 94%

Consider oxygen for a patient complaining of chest pain if the SpO2 is​ 92%

What organization developed the information that is to be included in the PCR minimum data​ set? A. U.S. Department of Health and Human Services B. Social Security Administration C. U.S. Department of Education D. U.S. Department of Transportation

Department of Transportation

You encounter a conscious and competent patient who now refuses treatment and transport. What should you​ do? A. Tell the patient he will die. B. Document the​ patient's refusal thoroughly and obtain necessary signatures. C. Simply leave the scene. D. Forcibly treat him.

Document the​ patient's refusal thoroughly and obtain necessary signatures. There are certain circumstances in which the standard PCR will not be appropriate.​ If, for​ example, the patient refuses care or​ transport, the EMT will have to document what attempts EMS made to get the patient to​ comply, and what the responses were to those attempts. Refusal​ forms, as they are called​ generically, are typically written in addition to a PCR.

When completing a​ paper-based prehospital care​ report, you accidentally write that a laceration was on the left side of a​ patient's face when it was actually on the right side of the face. Correcting this mistake would include which​ step? A. Carefully use​ White-Out to cover the term​ "left" but nothing else in the narrative B. Start the entire prehospital care report over from the beginning C. Color over the term​ "left" with black ink and write the word​ "right" next to it D. Draw a single line through the term​ "left" and write the word​ "right" next to it

Draw a single line through the term​ "left" and write the word​ "right" next to it

Which of the following terms describes inaccurate information that has been documented on a​ PCR, and may lead to revocation of EMT certification as well as possible criminal​ charges? A. Falsified B. Inaccurate C. Confidential D. Incomplete

Falsified

A prehospital care report​ reads: "GSW to​ LLQ." Based on​ this, you should recognize that the patient sustained​ a(n): A. Bullet injury to the left chest B. Injury to the left torso C. Gunshot to the lower left abdomen D. Puncture to the left chest

Gunshot to the lower left abdomen

An alert and oriented male patient with chest discomfort refuses treatment and transport to the hospital. He is angry with his family for calling 911 and refuses to sign the refusal of care form despite several requests. Which of these is your next best​ action? A. Carefully restrain the patient and place him on the stretcher for transport B. Call dispatch on a recorded telephone line and notify the dispatcher of the situation prior to departing the scene C. Have a family member sign as a witness to the​ father's refusal D. Contact the police to place the patient into protective custody

Have a family member sign as a witness to the​ father's refusal

Which of the following is NOT accurate when completing the vital signs division of the​ PCR? A. Document the time the​ patient's vital signs were taken. B. If you only take one set of vital​ signs, the second may be estimated. C. At least two complete sets of vital signs should be taken and recorded. D. Document the position the patient was in when vitals were taken.

If you only take one set of vital​ signs, the second may be estimated.

Which of the following is NOT a component of the minimum data​ set? A. Chief complaint B. Insurance information C. Skin​ color, temperature, and condition D. Blood pressure

Insurance information

What is an advantage of the computerized report over the traditional written​ report? A. It does not require the entry of as many sets of vital signs during patient contact. B. It can be linked to diagnostic and monitoring equipment. C. It requires the EMT to use proper​ spelling, as the report will be saved as is. D. The computer form is a scanned version of a paper form that is easier and cheaper to archive.

It can be linked to diagnostic and monitoring equipment. Computerized systems offer the promise of storing more information about a patient in a more legible format than written reports. They also allow greater efficiencies in​ storing, retrieving, and using data the EMT collects. The​ EMT's computer can be linked to diagnostic and monitoring​ equipment; to electronic medical​ records; to​ computer-aided dispatch​ (CAD); and to computer systems handling fleet​ management, inventory​ control, e-mail,​ personnel, and payroll.

You are giving a presentation to a group of new hires about your​ system's computer-based patient care report system. What might you identify as the greatest benefit of this​ system? A. It is the most common type of reporting system used today. B. It eliminates the need for the EMT to have a pen handy. C. It creates more legible written reports. D. It is cheaper than paper reports.

It creates more legible written reports.

You are working with a new EMT hire at your EMS company. You are showing him how to use the mobile data units when creating a PCR. He asks you why a PCR is even necessary. What should NOT be part of your​ answer? A. It has administrative purposes. B. It is intended to document the care provided. C. It is a legal document that stays with the​ patient's medical records. D. It is used as a document to identify when the EMT should be disciplined.

It is used as a document to identify when the EMT should be disciplined. The PCR can serve medical purposes​ (ensuring proper care is​ continuing), legal purposes​ (regarding what was done and not​ done), and administrative purposes​ (meaning things like CQI and​ billing). It is​ not, however, designed to be a disciplinary tool against the EMT authoring it.

Which statement describes an advantage of computerized​ documentation? A. A computerized reporting system is less expensive initially when compared to a system using handwritten PCRs B. Large amounts of data can be stored and retrieved much more easily than with handwritten PCRs C. A computer system does not need special​ maintenance; a system using handwritten run reports does D. There is much less documentation involved with electronic systems than with handwritten reports

Large amounts of data can be stored and retrieved much more easily than with handwritten PCRs

What type of special reporting situation typically employs the use of triage​ tags? A. ​Multiple-casualty incidents​ (MCIs) scenes B. Crime scenes C. Sporting event scenes D. Paediatric arrest scenes

Multiple-casualty incidents​ (MCIs) scenes During​ MCIs, such as plane crashes or​ multiple-vehicle collisions, rescuers are often overwhelmed with the number of patients requiring treatment. The needs of these patients can sometimes conflict with the need for complete documentation. In these​ cases, there may not be enough time to complete the standard PCR before turning to the next patient.​ Often, basic information such as chief​ complaint, vital​ signs, and treatment provided is recorded on a triage tag that is attached to the patient.

What is the name of the document in which the EMT should document all patient findings and​ treatment? A. General use statement B. Triage tag C. Medical chart D. PCR

PCR

Which section creates a thorough picture of the patient and his​ problem? A. Treatment B. Administrative information C. Patient narrative D. Vital signs

Patient narrative In narrative of the prehospital care report​ (PCR), you create a brief but thorough picture of the patient and his problem. Remember that you are recording details for other medical personnel to​ use, not presenting your own conclusions about an incident.

You are reviewing a prehospital care report​ (PCR) and note the following​ entry: "Pt. took PCN TID PO for 5​ days." You would interpret this as the patient​ took: A. Penicillin was taken orally three times a day for five days straight B. Three penicillin pills were taken every other day for five days C. Penicillin injections for five days in a​ row, three injections a day D. Antibiotic injections three times a day for five days

Penicillin was taken orally three times a day for five days straight

You have been called to the house of a patient with altered mental status. You encounter a​ 41-year-old male who exhibits slurred​ speech, an unsteady​ gait, and an odor resembling that of alcohol on his breath. His wife states that he is an alcoholic and needs help to get better. When documenting this​ information, which statement would be​ best? A. Family member states patient ETOH B. Per wife-patient has alcoholic history C. Alcoholic history disclosed to EMS D. Patient with history of alcoholism

Per wife-patient has alcoholic history

Which one of the following is an administrative use for the prehospital care report​ (PCR)? A. Quality improvement B. Preparing bills C. Research D. Legal defense

Preparing bills

Last​ week, on a​ computer-generated report, you accidentally documented that a patient suffered from hypertension​ when, in​ fact, he did not.​ Unfortunately, the report has been locked by the computer and cannot be​ changed; however, it can be printed. Your first action would be​ to: A. Retype the entire report and include the change B. Print the report and draw a line through the error C. Notify the medical director so that he or she can fix the error D. Contact the hospital and have the staff there change the information in the​ patient's medical record

Print the report and draw a line through the error

You are involved in a lawsuit over a stabbing that occurred six months ago. Since you work in a busy EMS system and some time has​ passed, your recollection of the incident in spotty. In this​ situation, your best means of remembering what occurred would be​ to: A. Confer with your partner at the time B. Obtain and review the police report C. Meet and discuss the incident with other witnesses D. Review the prehospital care report

Review the prehospital care report

The medical director states that it seems as if the number of patients suffering from shortness of breath with a history of congestive heart failure​ (CHF) has increased. She adds that she is thinking about modifying the​ protocols, but first must know the number of patients seen with this condition over the past year. To best determine the number of patients treated for this​ condition, you​ would: A. Have all employees complete a survey regarding the increase B. Question the emergency department physicians and nurses C. Review the previous prehospital care reports D. Have employees complete a form anytime they treat a patient with CHF

Review the previous prehospital care reports

A patient care report​ reads: "c/o fall with​ (R) hip​ pain; FROM to​ (R) low.​ ext." Based on​ this, you should recognize that the​ patient's: A. Right leg can be moved normally B. Right leg is not​ broken, but cannot be moved freely C. Right hip appears broken D. Right hip is​ dislocated, but not fractured

Right leg can be moved normally

A patient tells you that he has been feeling​ "very weak" for the past three days. Using the SOAP charting​ format, this information would be included under which​ heading? A. ​O: Objective B. ​S: Subjective C. ​P: Plan D. ​A: Assessment

S: Subjective

A patient states that he has had a headache located in his forehead for three days. The EMT should recognize and document this piece of information as​ a(n): A. Provoking factor B. Objective symptom C. Pertinent negative D. Subjective finding

Subjective finding

The EMT is completing documentation for the prehospital care report​ (PCR) and​ documents: "Patient​ states, 'Upon walking up the​ stairs, I became short of​ breath.'" Which type of information would this be​ considered? A. Patient medical history B. Subjective information C. Objective information D. Pertinent negatives

Subjective information

Which of the following bits of information should NOT be found in the treatment section of a patient care​ report? A. Indications of how the patient responded to treatments B. What treatments were rendered C. Subjective interpretation about the treatment rendered D. What time treatments were rendered

Subjective interpretation about the treatment rendered

While reviewing written PCR for your quality assurance​ committee, you come across a word that was misspelled. There was a single line drawn through​ it, and the correctly spelled word was next to it. Characterize how well the EMT corrected this mistake. A. The EMT corrected the mistake correctly. B. The EMT should have scribbled out the word to make it​ illegible, and then written the correct word. C. The EMT forgot to initial his mistake after striking out the wrong word and rewriting the correct one. D. The EMT was supposed to circle the incorrect​ word, write the correct word beside​ it, and then initial the change.

The EMT forgot to initial his mistake after striking out the wrong word and rewriting the correct one. Even the most careful EMT will occasionally make errors when filling out the PCR. When such an error is discovered while a paper report is being​ written, draw a single horizontal line through the​ error, initial​ it, and write the correct information beside it. Do not try to erase or write over the error. Such actions could be interpreted as attempts to cover up a mistake or falsify the report.

You have transferred care of a​ 21-year-old woman who overdosed on an unknown drug. For the​ patient, which best describes who is permitted access to the prehospital care report​ (PCR)? A. The health care provider assuming care of the patient B. The emergency physician but not the nurse C. The​ patient's mother but not brothers or sisters D. An​ on-duty police officer who is a friend of the patient

The health care provider assuming care of the patient

An intoxicated patient will not leave the oxygen mask on. What would be the most appropriate way to document this behavior on the prehospital care​ report? A. The patient continually removes the oxygen mask despite continued reapplication B. The patient is intoxicated and will not cooperate with oxygen therapy C. The patient appears to be in a​ drunk-like state and will not cooperate with care provided by EMS D. The patient will not cooperate with care provided by EMS

The patient continually removes the oxygen mask despite continued reapplication

A patient care report​ reads: "c/o chest pain with associated​ DOE; PMH of​ IDDM." Regarding this​ description, which interpretation is most​ accurate? A. The patient took insulin B. The patient is breathing easily C. The patient takes no medications D. The patient has diabetes

The patient has diabetes

Consider the following narrative from a patient care​ report: "pt. transported 3 days ago for suspected​ STEMI; pt. currently denies CP and​ SOB; PMH of HTN and​ CAD; pt. currently in​ NAD." Which of these interpretations is most​ accurate? A. The patient is in moderate distress B. The patient is short of breath C. The patient has heart problems D. The patient suffers from hypotension

The patient has heart problems

A patient care report​ reads: "PMH includes ESRF and​ (+) DNR;​ (+) ASA pta of​ EMS." Regarding this​ description, which interpretation is most​ accurate? A. The patient desires resuscitation B. The patient has kidney disease C. The patient is alert and oriented D. EMS administered aspirin to the patient

The patient has kidney disease

Which of the following is an example of a pertinent negative in a patient who is complaining of chest​ pain? A. The patient has a low blood pressure. B. The patient is not short of breath. C. The patient does not have blurred vision. D. The patient does not have a headache.

The patient is not short of breath. In questioning a​ patient, be alert for pertinent negatives. These are signs or symptoms that might be expected on the basis of the chief complaint but that the patient denies having. A pertinent negative might be a​ patient's denial of pain after an automobile crash or a lack of difficulty in breathing in a case of chest pain. By noting the absence of pertinent signs and​ symptoms, you will provide the medical team that takes over care of the patient a fuller picture of her condition.​ Typically, headaches, blurred​ vision, and low blood pressure are not common findings with chest​ pain, but respiratory distress is​ (so its absence is a pertinent negative in this​ patient).

A patient with asthma is using his inhaler TID and prn. You would recognize​ that: A. The patient uses his inhaler only when the symptoms are bad B. The patient is suffering asthmatic attacks three times a week C. The patient uses an inhaler at least three times a day D. The patient is prescribed his inhaler for use only three times a day

The patient uses an inhaler at least three times a day

Consider the following narrative from a patient care​ report: "pt. restrained passenger involved in 2 car​ MVC; c/o left lower leg pain rated​ 2/10; LOC​ A/O to​ person, place,​ time, and​ event; BBS​ clear; abd. Soft with tenderness​ LLQ; hx of NIDDM with am glucose level of 133​ mg/dL." Which of these interpretations is most​ accurate? A. The​ patient's abdomen appears uninjured B. The patient is being tested for diabetes C. The​ patient's lungs sounds are clear and equal bilaterally D. The patient is confused following the accident

The​ patient's lungs sounds are clear and equal bilaterally

Why are all PCRs done in the United States today supposed to have the minimum data set​ included? A. This allows better research and standardization of EMS care. B. It is required for Medicaid and Medicare to provide reimbursement. C. It shortens the overall length of the PCR. D. It allows the tracking of information to ensure the elderly population is managed correctly.

This allows better research and standardization of EMS care. The U.S. Department of Transportation​ (USDOT) has made an effort to standardize the information collected on PCRs. Such standardization​ will, it is​ hoped, lead to a higher general level of patient care across the nation. It will also permit more meaningful comparison and analysis of data from various​ systems, which may speed the implementation of new and better methods of emergency care. The minimum data set does not shorten the length of the​ PCR, nor is it required for billing​ reimbursement, and it was not designed to track the elderly population.

What type of PCR format requires the EMT to document patient information with an ink pen or other similar writing​ instrument? A. Electronic clipboard report B. Traditional computer report C. Traditional written report D. Hybrid computer report

Traditional written report

You have placed a​ 67-year-old female patient on​ low-concentration oxygen with a nasal cannula. Under which section of the prehospital care report​ (PCR) would you document this​ information? A. Patient data B. Administrative C. Treatment D. Patient narrative

Treatment

While transcribing the names of medications from the​ patient's bottles to your patient care​ report, you find a medicine bottle that is labelled as​ "APAP". What does this​ mean? A. Tylenol B. Naproxen C. Aspirin D. Ibuprophen

Tylenol ​"APAP" is the medical abbreviation for acetaminophen​ (generic name), or Tylenol​ (trade name).

Which of the choices is necessary for ensuring that the minimum data set is as accurate as​ possible? A. Use of paper PCR B. Use of​ computer-based PCR C. Use of accurate and synchronous clocks D. Use of integrated clipboard PCR formats

Use of accurate and synchronous clocks

Which of the following would NOT be appropriate when completing a​ PCR? A. Using accepted medical abbreviations B. Using anatomical language C. Documenting only facts about the patient D. Using abbreviations you have developed

Using abbreviations you have developed

Which item is included in the U.S. Department of Transportation minimum data​ set? A. Vital signs and skin condition B. Address and type of the call C. Insurance and billing information D. ​Patient's occupation

Vital signs and skin condition

The first​ "E" in the mnemonic CHEATED stands​ for: A. extremity. B. evaluation. C. effort. D. exam.

exam. E​ = exam, the information that was found in the physical examination of the patient.

When taking a history from the patient who is complaining of chest​ pain, a pertinent negative would​ include: A. the lack of prior heart attacks. B. his taking nitro and ASA. C. the lack of a history of allergies. D. the absence of breathing difficulty.

the absence of breathing difficulty. When questioning a​ patient, be alert for pertinent negatives. These are signs or symptoms that might be expected on the basis of the chief complaint but that the patient denies having. A pertinent negative might be a​ patient's denial of pain after an automobile crash or a lack of difficulty in breathing in a case of chest pain. By noting the absence of pertinent signs and​ symptoms, you will provide the medical team that takes over care of the patient a fuller picture of her condition.

Remember this EMS saying when filling out​ reports: "If it was not​ done, do​ not: A. do​ it." B. pretend it​ was." C. write it​ down." D. say​ it."

write it​ down."

Which statement regarding a PCR is​ accurate? A. ​"Aside from providing a record of the care​ given, the PCR also may be used for education and​ research." B. ​"The EMT should document only the direct care he or she​ provided, but not the care by EMRs since their report will reflect this​ care." C. ​"The PCR is a public record that becomes part of the​ patient's permanent medical​ record." D. ​"National standards allow the EMT to complete the PCR up to three days after the call as long as a verbal report was given to the​ physician."

​"Aside from providing a record of the care​ given, the PCR also may be used for education and​ research."

After a​ patient, who is short of​ breath, signs a refusal of service​ form, which statement would be appropriate prior to leaving the​ residence? A. ​"Try taking an aspirin and get a good​ night's rest; you will probably feel​ better." B. ​"If you change your mind at any time and want to be transported to the​ hospital, call 911​ again." C. ​"We will leave this oxygen for​ you; call us when you feel​ better." D. ​"Call our dispatch in the morning to let us know how you made​ out."

​"If you change your mind at any time and want to be transported to the​ hospital, call 911​ again."

You have transported a confused​ 46-year-old male who overdosed on an unknown drug to a busy emergency department. After giving an oral report to the ED​ nurse, your partner informs you that he wants to hurry back to the station so that he can watch the end of the football​ game; therefore, he is going to complete the patient care report​ (PCR) at a later time. How should you​ respond? A. ​"You really need to complete it before we leave. The hospital will not be able to get the​ patient's insurance information without the​ PCR." B. ​"If you do not complete and leave the​ PCR, the ED staff may not otherwise have access to information contained in the​ PCR." C. ​"Make sure that you give the nurse the telephone number to the station so she can call if there are any questions about the patient or our​ care." D. ​"If you do not leave the​ PCR, the emergency department staff will not know how to treat the​ patient."

​"If you do not complete and leave the​ PCR, the ED staff may not otherwise have access to information contained in the​ PCR."

When​ asked, an alert and oriented​ 44-year-old male tells you that he called 911 because​ "my chest is​ hurting." The man is also sweating and feels as if he is going to vomit. He has a history of high blood pressure and states that this pain​ "feels just like my heart attack two years​ ago." His pulse is 88 beats per​ minute, respirations are 18 breaths per​ minute, and blood pressure is​ 156/92 mmHg. On room​ air, he has an oxygen saturation level of 95 percent. Based on this​ information, how would you document his chief complaint on the patient care​ report? A. Myocardial infarction B. Chest pain with an elevated BP C. ​"My chest is​ hurting." D. Possible heart attack

​"My chest is​ hurting."

You have been called for a​ 2-year-old female with an arm injury. The child presents with deformity and bruising to her left forearm. When​ asked, the mother states that the child fell from the​ bed, but the father states that his daughter fell down the stairs. Given the inconsistent​ stories, you are suspicious of child abuse. Which narrative would be most appropriate when documenting this​ situation? A. ​"Patient fell off of bed injuring left arm-per ​mother; patient fell down stairs injuring left arm-per ​father." B. ​"Patient has injuries consistent with child​ abuse; the mother and father cannot determine how the patient was​ injured." C. ​"Mother and father cannot agree on how their daughter got the bruise and deformity to the​ arm." Your answer is not correct. D. ​"Patient appears to be​ abused; the police will be called and the physician in the ED will be​ notified."

​"Patient fell off of bed injuring left arm-per ​mother; patient fell down stairs injuring left arm-per ​father."

Your partner states that he is the​ "world's worst​ speller" and has great difficulty using medical terms. How would you respond to this​ statement? A. ​"Consider abbreviating medical terms that you are unsure how to​ spell." B. ​"Ask the emergency physician or nurse how to spell the words of which you are​ unsure." C. ​"Use everyday language if you are unsure of how to apply or spell a medical​ term." D. ​"Do not document information that requires medical terms you are unsure​ of."

​"Use everyday language if you are unsure of how to apply or spell a medical​ term."