Deck 4: Documentation

Question 1

A nauseated patient with fever and abdominal pain states that he has not vomited. Which one of the following describes how that fact should be documented?

A) As a treatment finding
B) As a subjective finding
C) As a pertinent negative
D) This fact would not be documented.

Answer 1

C

Question 2

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 form despite several requests. Which one of the following is your next best action?

A) Contact the police to place the patient into protective custody.
B) Have a family member sign as a witness to the father's refusal.
C) Call dispatch on a recorded telephone line and notify them of the situation prior to departing the scene.
D) Carefully restrain the patient and place him on the stretcher for transport.

Answer 2

B

Question 3

You have transferred care of a 21-year-old woman who overdosed on an unknown drug. For the patient, which of the following best describes who is permitted access to the prehospital care report (PCR)?

A) The emergency physician but not the nurse
B) The patient's mother but not brothers or sisters
C) An on-duty police officer who is a friend of the patient
D) The health care provider assuming care of the patient

Answer 3

D

Question 4

An intoxicated patient will not leave the oxygen mask on. How would this best be documented on the prehospital care report?

A) The patient is intoxicated and will not cooperate with oxygen therapy.
B) The patient continually removes the oxygen mask despite continued reapplication.
C) The patient will not cooperate with care provided by EMS.
D) The patient appears to be in a drunk-like state and will not cooperate with care provided by EMS.

Question 5

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) subjective finding.
B) pertinent negative.
C) objective symptom.
D) provoking factor.

Question 6

After a patient, who is short of breath, signs a refusal of service, which one of the following statements would be appropriate prior to leaving the residence?

A) "We will leave this oxygen for you; call us when you feel better."
B) "Try taking an aspirin and get a good night's rest; you will probably feel better."
C) "Call our dispatch in the morning to let us know how you made out."
D) "If you change your mind and want to be transported to the hospital, call 911."

Question 7

After oxygen therapy, the patient's SpO₂ improves from 90% to 99%. Using the CHEATED method of documentation, this would be placed in which category?

A) C-Chief complaint
B) H-History
C) E-Evaluation
D) D-Disposition

Question 8

Which item would the EMT place in the administrative information section of the prehospital care report?

A) BLS Unit 51-20; Incident # 67-8971-90
B) Patient: Henry, Steven M
C) "Patient found supine on the porch."
D) Blue State Insurance #425-22892; GRP# 456298

Question 9

A patient tells you that he has been feeling "very weak" for the past three days. In regards to the SOAP charting format, this information would be included under what heading?

A) S-Subjective
B) O-Objective
C) A-Assessment
D) P-Plan

Question 10

You have placed a 67-year-old female patient on low-concentration oxygen with a nasal cannula. Under what section of the prehospital care report (PCR) would you document this information?

A) Administrative
B) Patient data
C) Patient narrative
D) Treatment

Question 11

Which one of the following items is included in the U.S. Department of Transportation minimum data set?

A) Insurance and billing information
B) Vital signs and skin color
C) Address and type of the call
D) Patient's occupation

Question 12

Which one of the following patients who refuse treatment must be transported to the hospital?

A) 16-year-old female who lives in her parents' house and has a child
B) Alert and oriented 57-year-old male who is having chest pain and is diaphoretic
C) A homeless man in his 50s who is dirty and disheveled and has a body-wide rash
D) 29-year-old female who attempted to cut her wrists earlier but now states it was an accident and she is not suicidal

Question 13

While moving a 67-year-old male complaining of dizziness from his residence on the stretcher, you stumble backward and knock a statue 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), which of the following should be included?

A) The fact that property damage occurred
B) A factual account of your ankle injury
C) The patient's insurance information
D) An objective statement about the family displeasure

Question 14

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. Which one of the following is now your best course of action?

A) Complete a new refusal and return to the patient's residence to have him re-sign the refusal form.
B) Add an addendum to the report with the correct information, current date, and the EMT's initials.
C) Report the error to the State Department of the Emergency Medical Services.
D) Disregard the mistake since the patient was not transported to the hospital and medical direction was aware of the blood glucose reading.

Question 15

Which one of the following describes the EMT's most objective finding?

A) Complaint of nausea
B) Blood pressure 114/68 mmHg
C) Patient rates pain as 10 out of 10
D) Complaint of headache for past 12 hours

Question 16

When writing a prehospital care report, you accidentally document that a laceration was on the left side of a patient's face when it was actually on the right side of the face. How would you correct this mistake?

A) Color over the term "left" with black ink and write the word "right" next to it.
B) Start the entire prehospital care report over from the beginning.
C) Carefully use White-Out to cover the term "left" but nothing else in the narrative.
D) Draw a single line through the term "left" and write the word "right" next to it.

Question 17

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 though 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 per minute, and blood pressure is 156/92 mmHg. On room air, he has an oxygen level of 95%. Based on this information, how would you document his chief complaint on the patient care report?

A) "My chest is hurting."
B) Possible heart attack
C) Myocardial infarction
D) Chest pain with an elevated BP

Question 18

Which one of the following statements shows an accurate understanding of the legal aspects of the prehospital care report (PCR)?

A) "The PCR is considered a legal document only when it describes a crime or act of violence."
B) "A PCR can be used in a lawsuit only if that lawsuit is filed within six months."
C) "The PCR may be subpoenaed even if the case centers around alleged negligence that occurred in the emergency department."
D) "A copy of the PCR should be forwarded to the police any time law enforcement is involved in the call."

Question 19

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) "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."
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) "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."
D) "If you do not leave the PCR, the emergency department staff will not know how to treat the patient."

Question 20

When getting a refusal from a patient who does not want the services of EMS, it is critical for the EMT to do which one of the following?

A) Make sure that the patient is under 65 years of age.
B) Have the patient sign and date the refusal form.
C) Make sure that the hospital is notified.
D) Make sure the patient has another way to get to the hospital.

Question 21

Your protocol reads: "O₂ via NC prn if asymptomatic for CP / SOB and SpO₂ >97%." To follow this order, you should do which one of the following?

A) Call medical command to administer oxygen if the pulse oximeter reading is above 97%.
B) Consider oxygen for a patient complaining of a runny nose and SpO₂ at 98%.
C) Administer oxygen via face mask if the patient denies a complaint and has a pulse oximeter reading of 98%.
D) Administer oxygen through a nasal cannula at three liters per minute if the pulse oximeter reads 96%.

Question 22

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 of the following is true?
(A) The patient has a headache.
(B) The patient has a history of drug problems.
(C) The patient is nauseated but not vomiting.
(D) The patient has a history of migraines.

Question 23

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 one of the following narratives 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) "Mother and father cannot agree on how their daughter got the bruise and deformity to the arm."
C) "Patient has injuries consistent with child abuse; the mother and father cannot determine how the patient was injured."
D) "Patient appears to be abused; the police will be called and the physician in the ED will be notified."

Question 24

A patient care report reads: "c/o chest pain with associated DOE; PMH of IDDM." Regarding this description, which one of the following is true?

A) The patient is a diabetic.
B) The patient is breathing easily.
C) The patient takes no medications.
D) The patient took nitroglycerin.

Question 25

Which one of the following statements about PCRs is accurate?

A) "The PCR is a public record that becomes part of the patient's permanent medical record."
B) "Aside from providing a record of the care given, the PCR also may be used for education and research."
C) "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."
D) "The EMT should only document the direct care he or she provided and not the care by EMRs since their report will reflect this."

Question 26

You are reviewing a prehospital care report (PCR) and note the following entry: "Pt. took PCN b.i.d. PO for 5 days." You would interpret this as the patient took:

A) penicillin injections for five days.
B) a total of 10 pills of penicillin.
C) a penicillin pill every other day for five days.
D) antibiotic injections two times a day for five days.

Question 27

A patient care report reads: "c/o fall with (R) hip pain; FROM to (R) low. ext." Based on this, you should recognize which one of the following?

A) Right hip appears broken.
B) Right hip is dislocated, but not fractured.
C) Right leg can be moved normally.
D) Right leg is not broken, but cannot be moved freely.

Question 28

A prehospital care report reads: "GSW to torso (LLQ)." Based on this, you should recognize that the patient sustained a(n):

A) gunshot to the left chest.
B) injury to the left torso.
C) bullet injury to the left chest.
D) injury to the lower abdomen.

Question 29

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) review the prehospital care report.
(B) meet and discuss the incident with other witnesses.
(C) confer with your partner at the time.
(D) obtain and review the police report.

Question 30

A patient care report reads: "PMH includes ESRF and (+) DNR; (+) ASA pta of EMS." Regarding this description, which one of the following is true?

A) The patient is alert and oriented.
B) The patient has kidney disease.
C) The patient desires resuscitation.
D) EMS administered aspirin to the patient.

Question 31

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 doing so, you realize that incorporating this data into your report form will:

A) increase EMS funding received from the federal and state governments.
B) allow easier comparison of specific EMS data between various types of emergency systems.
C) work toward creating a single report form for all EMS systems that handle emergency calls.
D) permit easier tracking of motor-vehicle collisions so that hazardous roads and intersections can be identified.

Question 32

Your partner states that he is the "world's worst speller" and has great difficulty using medical terms. Which one of the following statements is appropriate?

A) "Ask the emergency physician or nurse how to spell the words of which you are unsure."
B) "Use plain English if you are unsure of how to apply or spell a medical term."
C) "Consider abbreviating medical terms that you are unsure how to spell."
D) "Do not document information that requires medical terms you are unsure of."

Question 33

Which one of the following describes an advantage of computerized documentation?

A) A computerized reporting system is less expensive initially when compared to a system using handwritten PCRs.
B) A computer system does not need special maintenance; a system using written run reports does.
C) Large amounts of data can be stored and retrieved much easier than with the written PCR.
D) There is much less documentation involved with electronic systems than with written reports.

Question 34

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 has an odor of alcohol on his breath. His wife states that he is an alcoholic and needs help to get better. When documenting this, which one of the following would be best?

A) Alcoholic history disclosed to EMS
B) Patient with history of alcoholism
C) Family member states patient ETOH
D) Per wife-patient with alcoholic history

Question 35

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

Question 36

Which one of the following 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) Ensures that all EMS staff is on time and ready for the shift
B) Allows the supervisor to make sure that all EMTs have a watch
C) Provides the best opportunity for the EMT to end the shift on time
D) Promotes accurate system-wide time record keeping throughout the shift

Question 37

The medical director states that it seems there has been an increase in the number of patients suffering from shortness of breath with a history of congestive heart failure (CHF). He adds that he 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) question the emergency department physicians and nurses.
(B) review the previous prehospital care reports.
(C) have employees complete a form any time they treat a patient with CHF.
(D) have all employees complete a survey regarding the increase.

Question 38

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) give a verbal report to the ED physician.
B) repeat your assessment findings and treatment to the nurse.
C) complete an abbreviated transfer-of-care form.
D) leave and return to complete the report as soon as possible.

Question 39

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) contact and question the bystanders.
(B) call the EMTs at home.
(C) question the patient.
(D) check the prehospital care report.

Question 40

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 and 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 emergency department chart in court.
(B) testimony from your supervisor stating that you always place a cervical collar.
(C) written documentation of collar placement on the PCR.
(D) presentation of the standard of care showing that a cervical collar is indicated.

Question 41

A patient with asthma is using his inhaler tid and prn. You would recognize that:
(A) the patient is only prescribed his inhaler three times a day.
(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 uses his inhaler only when the symptoms are bad.

Question 42

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) contact the hospital and have them change it in the patient's medical record.
(D) notify the medical director so that she can fix the error.

Question 43

A pertinent negative would be illustrated by:
(A) "nausea without vomiting."
(B) "hypertension and taking medication."
(C) "dizziness for three days without notifying the doctor."
(D) "short of breath with history of lung problems."

Question 44

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 the following is true?
(A) The patient's abdomen appears uninjured.
(B) The patient is being tested for diabetes.
(C) The patient is confused following the accident.
(D) The patient's lungs sounds are clear and equal.