Deck 15: Communication and Documentation

Question 1

Why is it important to notify medical control as soon as practical about your patient's condition?

A) It provides legal protection as patient care now becomes their responsibility.
B) It allows the receiving facility more time to prepare for your arrival.
C) It is common courtesy.
D) It minimizes the chance that you will forget to contact medical control.

Answer 1

It allows the receiving facility more time to prepare for your arrival.

Question 2

Which of the following is NOT considered a principle of proper radio usage in EMS?

A) Speak with your lips 2 to 3 inches from the microphone.
B) Speak as quickly as possible.
C) Use plain English.
D) Make sure the radio is on before speaking.

Answer 2

Speak as quickly as possible.

Question 3

During your radio report to the hospital,which of the following pieces of information should NOT be relayed?

A) Patient's age
B) Baseline vital signs
C) Patient's name
D) Patient's status

Answer 3

Patient's name

Question 4

When giving a radio report to the hospital,which of the following would be the first patient-specific information provided?

A) The patient is complaining of chest pain.
B) The patient has taken nitroglycerin.
C) The patient is a 55-year-old male.
D) The patient is having a heart attack.

Question 5

Why is it important to NOT give the name or Social Security number of your patient over the ambulance radio when contacting medical control?

A) It is illegal.
B) Someone may steal the patient's identity.
C) Someone may know the patient and tell the patient's friends.
D) It is unnecessary.

Question 6

Which of the following BEST describes a repeater?

A) A two-way radio that is mounted in a vehicle
B) A two-way radio that can be carried on a belt clip
C) A device that receives and amplifies a signal that must be carried over long distances
D) A two-way radio at a fixed site

Question 7

Which of the following BEST describes a mobile radio?

A) A two-way radio that can be carried on a belt clip
B) A two-way radio that is mounted in a vehicle
C) A two-way radio at a fixed site
D) A device that receives and amplifies signals that must be sent over a long distance

Question 8

You are en route to the hospital with a 22-year-old male patient who has suffered a very embarrassing injury to his genitalia.Which method of contacting the receiving facility will afford the patient the most privacy?

A) Using the handheld radio
B) Using the ambulance radio but not using the patient's name
C) Using the ambulance radio but not providing details of the injury
D) Providing the receiving hospital with all information via a cell phone

Question 9

Which of the following agencies assigns and licenses radio frequencies?

A) United States Department of Transportation
B) Transportation Security Administration
C) Federal Trade Commission
D) Federal Communications Commission

Question 10

Which of the following is NOT part of a medical radio report?

A) Estimated time of arrival
B) Address at which the patient was located
C) Unit identification
D) Patient's response to medical care provided

Question 11

Which of the following BEST describes a base station?

A) A two-way radio at a fixed site
B) A device used to receive and then amplify transmissions that must be carried over long distances
C) A two-way radio mounted in a vehicle
D) A two-way radio that can be carried on a belt clip

Question 12

You are transporting a city councilman to the hospital after he injured his shoulder playing basketball at his gym.His left shoulder is swollen,deformed,and bruised.There is pain and tingling when the patient attempts to use his hand.He has a pulse of 92 per minute,a respiratory rate of 20 per minute,and a blood pressure of 132/88 mmHg.Which of the following should NOT be included in the radio report?

A) The appearance of the shoulder
B) Notification that extra security is needed for a VIP
C) How the injury occurred
D) Vital signs

Question 13

You have an urgent transmission you need to make to the dispatch center.Which of the following is the appropriate way to communicate this?

A) Interrupt less urgent radio traffic to get your message across.
B) Speak loudly to convey the urgency of the message.
C) Listen to the frequency first to avoid stepping on another transmission.
D) Use the phrase, "Attention, attention, I have priority traffic."

Question 14

You have received the following order from medical control: "Administer one tablet of nitroglycerin under the patient's tongue." Which of the following is the BEST response?

A) "Roger, order received."
B) "Order received. One nitroglycerin tablet under the patient's tongue."
C) "Clear. Will advise of any changes in patient's condition."
D) "Copy. Administering medication now."

Question 15

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?

A) Cell phone at the scene
B) Landline at the patient's house
C) Ambulance mobile radio
D) Portable radio at the residence

Question 16

Which of the following is NOT appropriate for inclusion in the radio report to the receiving hospital?

A) Physical exam findings
B) The patient's mental status
C) Name of the patient's health insurance provider
D) Pertinent past illnesses

Question 17

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

A) Estimated time of arrival at the hospital
B) Which hospital you are transporting to
C) When you depart from the hospital
D) When you arrive at the hospital

Question 18

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

A) 12
B) 8
C) 5
D) 10

Question 19

Why is it important that your radio report to the receiving facility be concise?

A) The emergency department needs to know quickly and accurately the patient's condition.
B) You do not want to bore the nurse receiving your report.
C) You want to make sure the doctor approves your medical order request.
D) You want to appear professional.

Question 20

Which of the following BEST describes a portable radio?

A) A device that receives and amplifies signals that must be sent over long distances
B) A two-way radio that is mounted in a vehicle
C) A two-way radio at a fixed site
D) A two-way radio that can be carried on a belt clip

Question 21

What is the best way to communicate with a young pediatric patient?

A) Only talk with the parents. The child is too young to know his or her medical history.
B) Sit at the level of the child, if possible, and always be honest.
C) Do not tell the child that a procedure will hurt beforehand because the child will become terrified.
D) Tell the child the procedure will hurt much more than it actually will so he or she will be pleasantly surprised when the procedure is over.

Question 22

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

A) It shows you are confident.
B) It shows you are attentive.
C) It shows you are interested in the patient.
D) Eye contact is always appropriate.

Question 23

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

A) The patient had a respiratory rate of 44.
B) The patient was confused.
C) The patient stated that she felt sick.
D) The patient was found sitting in the driver's seat of a full-size sedan.

Question 24

Which of the following BEST describes the position you should take when dealing with a cooperative patient who is sitting in a chair?

A) Sit or kneel at the same level as the patient.
B) Stand behind the patient's chair.
C) Stand next to the chair.
D) Sit on the floor at the patient's feet.

Question 25

Which of the following should be placed in quotes in the patient care report?

A) Patient's expressed consent
B) Chief complaint
C) List of patient's medications
D) Mechanism of injury

Question 26

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?

A) "If you're stressed out like this, it's going to hurt a lot more."
B) "Relax, this is not a painful procedure."
C) "I will do my best, but it may hurt while we put the splint on."
D) "It doesn't matter, we have to do it anyway."

Question 27

You are treating a 32-year-old man who is deaf.You need to find out why he called for an ambulance.What is the BEST way to communicate with this patient?

A) Use hand gestures to act out what you are trying to say.
B) Make sure the patient can see your lips when you speak.
C) Call for an interpreter to meet you at the hospital.
D) Speak very loudly in case he has a little hearing.

Question 28

Your elderly male patient tells you his name is Joe Smith.Which of the following is the BEST way to address him?

A) Joe
B) Smitty
C) Mr. Smith
D) Sir

Question 29

While on the scene with an elderly chest pain call,you notice that your partner gets on one knee when talking to the seated patient.What is the best reason for an EMT to kneel down beside the patient?

A) The younger EMT is acknowledging that the older patient is his elder.
B) The EMT is kneeling to protect himself.
C) The EMT can examine the patient's chest better.
D) The EMT does not want to appear threatening or intimidating to the patient.

Question 30

Which of the following is NOT an appropriate way of dealing with a patient who does not speak the same language as you do?

A) Avoid communicating with the patient so there is no misunderstanding of your intentions.
B) Use an interpreter.
C) Contact dispatch for assistance in finding a translator.
D) Use a manual that provides translation.

Question 31

When you arrive at the receiving facility,the nurse asks your partner for a verbal report of the patient's condition.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) The nurse may not have heard the first radio report.
B) The nurse may have to perform critical interventions on the patient before you complete your written report.
C) The patient's condition may have changed since the first radio report.
D) The nurse may be too busy to read the written report.

Question 32

You are on the scene of an unresponsive adult female patient.You find an empty pill bottle lying next to her bed.You look up the medication in your field guide and discover the medication is a powerful sedative.The prescription on the bottle is for the patient's husband,who is not present to answer questions about the medication.What should you do?

A) Document the empty pill bottle. It may provide important clues to the patient's condition.
B) Do not document the empty pill bottle. It does not belong to the patient.
C) Document the empty pill bottle. It is obvious that she took the pills.
D) Do not document the empty pill bottle. You cannot prove that she took the pills and could lead the doctor to make a false diagnosis.

Question 33

Which of the following information on a patient care report is NOT considered run data?

A) Chief complaint
B) Other EMS units on the scene
C) Location of the call
D) Time of arrival at the receiving facility

Question 34

Which of the following describes the importance of effective communication of patient information in the verbal report?

A) Patient treatment can be based on this information.
B) Additional information that was not given in the radio report can be provided.
C) Changes in the patient's condition can be communicated.
D) All of the above

Question 35

An objective statement made in a prehospital patient care report meets all of the following criteria except which one?

A) Verifiable
B) Observable
C) Measurable
D) Biased

Question 36

The portion of the patient care report in which the EMT writes his description of the patient's presentation,assessment findings,treatment,and transport information is called the:

A) text.
B) data set.
C) deposition.
D) narrative.

Question 37

You are responding to a nursing home for an 85-year-old patient complaining of difficulty breathing.How would you initiate contact with this patient?

A) Stand near the head of the bed and shout to make sure the patient can hear you.
B) Place yourself at eye-level, identify yourself, and ask the patient what she would like to be called.
C) Sit on the foot of the bed and ask the patient what's up.
D) Pick up the patient's wrist and begin taking her pulse.

Question 38

You have received an order from medical direction that you feel would be detrimental to your patient.Which of the following should you do?

A) Politely question the physician.
B) Carry out the order but document that you disagreed with it.
C) Contact your supervisor for advice.
D) Call a different hospital for orders.

Question 39

You are attempting to place a nonrebreather mask on a patient who is experiencing difficulty breathing.The patient is anxious and does not want the mask on his face.Which of the following is the BEST course of action?

A) Tell the patient the mask is for his benefit and you will restrain him if necessary to place it on him.
B) Explain the importance of oxygen and ask the patient to at least try to leave the mask on, but that if he can't tolerate it you can try another method.
C) Tell the patient he will soon become unconscious without the mask and then you will be able to place it on him.
D) Document that the patient was uncooperative and refused oxygen.

Question 40

Medical direction has requested that you administer 70 grams of activated charcoal to an overdose patient.Which of the following should you do next?

A) Document the order in writing before carrying it out.
B) Repeat the order back to the physician to make sure you understood correctly.
C) Administer the medication without delay.
D) Prepare the medication and then call the hospital back to re-confirm the order.

Question 41

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

A) Medications
B) Signs
C) Description of the surroundings
D) Symptoms

Question 42

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?

A) Get permission from medical control.
B) Ask the patient if it is alright with her if you provide the individual with a copy of the patient care report.
C) State that you are unable to comply with the request due to patient confidentiality.
D) Provide the documentation if the individual shows proper identification.

Question 43

The Health Insurance Portability and Accountability Act (HIPAA)requires ambulance services to do all of the following except:

A) place patient care reports in a locked box.
B) safeguard patient confidentiality.
C) report child abuse.
D) All of the above are required by HIPAA.

Question 44

Patient data includes all of the following except the:

A) nature of the dispatch.
B) patient's medications.
C) patient's chief complaint.
D) mechanism of injury.

Question 45

Two EMTs 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?

A) The fact that the patient was violent and bit the EMT
B) The fact that the EMT had an exposure incident
C) The fact that the patient hears voices
D) The fact that the patient slashed his wrists

Question 46

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?

A) Loss of credibility
B) Embarrassment
C) Negative impact on patient care
D) All of the above

Question 47

You are on a call of a minor vehicle accident.Your patient is a 22-year-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?

A) No report is needed because the patient refused transport and signed the refusal.
B) You should only document what treatment you performed before the patient refused treatment.
C) 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.
D) You should document your patient care and then simply document that the patient was informed of the risks prior to his refusal. Anything extra is unnecessary and wastes time.

Question 48

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

A) Patient's subjective statements
B) Radio codes
C) Pertinent negative findings
D) Chief complaint

Question 49

In which of the following circumstances is a fully documented patient care report NOT necessary?

A) A patient is treated but not transported.
B) Multiple patients come from an office building evacuation.
C) A patient says that someone else called EMS and he does not want any assistance.
D) A fully documented patient care report is required for all of the above.

Question 50

Which of the following pieces of legislation applies to use of information on a patient care report?

A) FERPA (Family Educational Rights and Privacy Act)
B) EMTALA (Emergency Medical Treatment and Labor Act)
C) COBRA (Consolidated Omnibus Budget Reconciliation Act)
D) HIPAA (Health Insurance Portability and Accountability Act)

Question 51

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?

A) Patient's insurance coverage
B) Amount charged for ambulance services
C) Patient's name
D) Time of arrival at the patient's location

Question 52

Which of the following does NOT need to be documented regarding a patient refusal of treatment?

A) That you informed the patient of the consequences of refusing care
B) Patient's mental status
C) Any insulting remarks the patient made to you
D) That you advised the patient to call back if he changed his mind

Question 53

Which of the following is NOT an objective element of documented patient information?

A) Position in which the patient was found
B) Patient's complaint of nausea
C) Patient's blood pressure
D) Patient's age

Question 54

Which of the following is NOT an appropriate use of patient care report (PCR)information?

A) To conduct research
B) To provide EMS personnel with education and quality assurance
C) For billing and insurance purposes
D) For referral to Alcoholics Anonymous or similar social services

Question 55

Which of the following is the most common situation in which an EMT may be liable?

A) Patient refusal of treatment and transport
B) Failing to get the receiving physician's signature on the patient care report
C) Failure to document all of a patient's medications on the patient care report
D) Inaccurate recording of times and mileage

Question 56

Which of the following is NOT an appropriate statement for the EMT to make on a patient care report?

A) The patient complains of difficulty breathing.
B) The patient had wheezes that were audible without using a stethoscope.
C) The patient has a history of asthma.
D) The patient was having an asthma attack.

Question 57

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

A) Get a credible witness to co-sign your patient care report.
B) Draw a single line through the error and initial it.
C) Use typing correction fluid to cover up the error and write over it.
D) Blacken out the entire error and draw an arrow to the correct information.

Question 58

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

A) Assess conformity to patient care standards
B) Review excellent patient care
C) Review poor patient care
D) Satisfy requirements of the shift supervisor

Question 59

You suspect that a 6-year-old female patient with multiple bruises and a broken wrist was abused.The stepmother states the patient fell down 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?

A) Document who you suspect caused the injuries in the narrative so law enforcement has a record of the incident.
B) Document what was said as well as your opinion that the child was too afraid to tell the truth.
C) Document only the actual exam findings. Do not document anything that was said.
D) Document any pertinent information that was said by the stepmother and child exactly in quotations.

Question 60

Which of the following is NOT appropriate to document on your patient care report?

A) Patient's attitude
B) Patient's mental status
C) Patient's race
D) All should be documented

Question 61

The QI manager calls your partner into his office after your shift.He pulls out his EMS report on a call he ran last month on a 45-year-old driver of a single-vehicle motor vehicle collision.There were several empty beer cans in the patient's vehicle and the EMT detected an odor of alcoholic beverages on the patient's breath.The QI manager,however,critiques your partner about calling the patient an alcoholic and giving opinions in the report.He tells your partner to never write opinions in the EMS report.Your partner is confused because he is sure the patient was drunk,and he was actually arrested for suspicion of driving while intoxicated.Your partner believes his assessment is supported by facts and not just his opinion.How can you help your partner understand the QI manager's concerns?

A) Calling the patient an alcoholic is not polite, even if it is true.
B) The QI manager is afraid the patient will sue the EMS service for libel.
C) Documenting that the patient is an alcoholic gives an incorrect opinion of the patient that is not supported by facts, and could negatively influence other medical providers.
D) The patient is assumed to be innocent until proven guilty. He is not an alcoholic until he is convicted of drinking and driving by a court of law.