Deck 19: Documentation

Question 1

The final element in AMPLE (E) refers to examination.

Answer 1

False

Question 2

The CHEATED format works well for documentation of refusal of medical assistance (RMA).

Answer 2

True

Question 3

The documentation of the protocol-driven field diagnosis asserts and reinforces the Paramedic's medical control.

Answer 3

True

Question 4

A(n) ____ is the testimony of a witness in a setting outside of a court, where attorneys from both parties can interrogate the witness.

A) declaration
B) affidavit
C) deposition
D) subpoena

Question 5

All interventions performed, both BLS and ALS, should be noted in the disposition section of the PCR.

Question 6

The last section of the CHEATED PCR is ____.

A) disposition
B) character
C) temperament
D) outlook

Question 7

During a mass casualty incident, the ____ is the only documentation that will be performed.

A) outcome tag
B) assessment tag
C) briefing tag
D) triage tag

Question 8

The ____ is a chronological description of the development of the patient's present illness, starting with the patient's chief complaint.

A) medical audit
B) history of present illness
C) alert report
D) chief complaint

Question 9

The PCR is essential to the continuity of patient care.

Question 10

The ____ examination assesses the patient's general appearance.

A) statutory
B) professional
C) constitutional
D) overall

Question 11

____ are a careful review of the documentation for specific data.

A) Patient audits
B) Mortality audits
C) MMR audits
D) PCR audits

Question 12

One study suggested that Paramedics spend as much as ____% of their patient contact time writing the patient care report (PCR), underscoring its importance.

A) 12
B) 16
C) 28
D) 41

Question 13

The central question with facsimiles is ____.

A) integrity
B) accuracy
C) confidentiality
D) discretion

Question 14

Under most circumstances, the ____ for the agency receives an exposure report and would make recommendations for corrections to prevent problems in the future.

A) information officer
B) designated officer
C) incident officer
D) operations officer

Question 15

When an error is made on the PCR, the Paramedic should "strike-out" the mistake with a single line, leaving the content below the strike-out legible.

Question 16

The assessment is partially a protocol-driven medical decision.

Question 17

The ____ means that another person, not a physician, who was in the same or similar circumstances would think it is appropriate to call EMS.

A) prudent layperson standard
B) emergency care standard
C) due diligence standard
D) confidentiality standard

Question 18

If the patient is a low-priority patient, then a less detailed physical examination is performed.

Question 19

Traditional documentation has several advantages over electronic documents.

Question 20

Slang and jargon are commonly used in a PCR to communicate messages effectively.

Question 21

A(n) ____________________ data set requires that the Paramedic complete certain fields with the requested information.

Question 22

A PCR has many ____________________, which are places to enter data.

Question 23

After a deposition is taken, a(n) ____________________, which is a word-for-word account, is then produced for use in the lawsuit and may be submitted into evidence in a court of law.

Question 24

Following every treatment there should be a(n) ____________________ of the effectiveness of that treatment, or, at a minimum, a statement about the patient's ongoing condition.

Question 25

____________________ documentation is a record of the pertinent findings and observations of the patient's health obtained through examination.