Paramedic Care: Principles & Practice, 4th edition

Bledsoe/ Porter/ Cherry

Volume 1 Introduction to Paramedicine

Chapter 10 Documentation

1) The subjective narrative includes information that is elicited:

A) During history taking
B) Through palpation
C) By observing the patient’s actions
D) From dispatch information

2) The best method for completing the narrative section of the PCR is:
A) Dependent on the nature of the call
B) The CHART format
C) The patient management format
D) The SOAP format

3) An addition or a supplement to an original report is called a(n):

A) Supplement
B) Add-on
C) Addendum
D) Appendix

4) When your patient refuses care and transportation, even though you have communicated to the
patient that you feel it is necessary, the patient is refusing:
A) Against medical control (AMC)
B) With poor judgment (WPJ)
C) With informed consent (WIC)
D) Against medical advice (AMA)

5) The paramedic’s general impression is documented in the:

A) Subjective narrative
B) Assessment/management plan
C) Objective narrative
D) Diagnosis section

6) Which of the following refers to the time between dispatch of a unit and its arrival on the
scene?
A) On-scene
B) Response
C) Dispatch
D) Transport

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7) What is the problem with the treatment in the following narrative?
The pt. complained of chest pain x 2 days before calling EMS and is now also c/o SOB. Vitals
BP 90/50, HR 40, labored with retractions. Treated with O2 and atropine. Upon arrival the pt.
felt better.
A) No dosages are stated.
B) The patient should have received transcutaneous pacing.
C) Nothing documented supports the treatment given.
D) A and C are both problematic.

8) The format that uses a chronological account from the time of arrival on scene to the time of
transfer of care is known as:
A) Patient management
B) Body systems
C) Head-to-toe
D) SOAP

9) The only truly factual record of the events on an EMS call is the:
A) Emergency department chart
B) Prehospital care report
C) Communications center report
D) Medical control report

10) Pertinent clinical information should be documented in the:

A) Subjective narrative
B) Objective narrative
C) Treatment section
D) Clinical narrative

11) An essential component of good documentation is the appropriate use of:

A) Subjective opinions
B) Administrative research
C) Medical terminology
D) Medical metaphors

12) Which of the following documents containing vital information is affixed to the patient
during large-scale incidents with multiple patients?
A) Medic Alert tags
B) PCRs
C) MCI narratives
D) Triage tags

13) What is the correct abbreviation for potassium?

A) K++
B) K-
C) K+
D) K

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14) Which of the following allows you to increase the amount of information you can quickly
and efficiently write on your PCR?
A) Acronyms and abbreviations
B) Pertinent negatives
C) Time stamps
D) Medical terms

15) Which of the following types of records provides the basis for continuous improvement of
patient care in the EMS system?
A) EMS supervisor administrative reports
B) Medical control radio logs
C) Prehospital care reports
D) The dispatch center log

16) The prehospital care report should document all of the following, EXCEPT:
A) Objective observations
B) Treatments provided
C) Pertinent negatives
D) Subjective opinions

17) You are completing your PCR and cannot remember the correct spelling of a medical term.
You should:
A) Try to spell the word, even if you are wrong
B) Make up an abbreviation for the word
C) Cross out the sentence and indicate an error
D) Use plain English instead

18) The abbreviation Hgb stands for:

A) Millimeters of mercury
B) Hematocrit
C) History
D) Hemoglobin

19) What is one of the common problems with documenting times?

A) Medical terminology
B) Abbreviations and acronyms
C) Inconsistencies between dispatch and ambulance clocks
D) Check boxes

20) Confidentiality of a patient’s prehospital care report is:

A) Forfeited by the patient when he consents to treatment
B) Not applicable to patients who are not expected to survive
C) Not applicable to noncitizens
D) The patient’s legal right

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21) Which of the following individuals may make changes and additions to the original chart?
A) The medical direction physician
B) The original author’s partner
C) The original author
D) All of the above

22) Missing information, inaccurate data, and illegible documentation all give the impression of
a(n):
A) Incompetent provider
B) Busy shift
C) Typical EMS patient care report
D) Practiced paramedic whose reputation speaks for itself

23) You respond to a call and the police and fire departments are on the scene, as well as a
physician. Which of the following should you mention in your PCR?
A) Fire department only
B) Fire department and the physician only
C) Police, fire, and the physician
D) Police only

24) A well-written prehospital care report is:

1. Accurate
2. Legible
3. Without alterations
4. Professional
A) 1 and 2 only
B) 1, 2, and 4
C) All of the above
D) None of the above

25) When using direct patient statements, you should:

A) Identify the quote with quotation marks
B) Have your partner or another witness initial the statement
C) Subjectively interpret and record them
D) Have the patient initial his agreement with them, if his condition permits

26) When possible, who should be asked to read and review the PCR before you submit it as
complete?
A) Only you and your partner
B) Only you
C) Only you, your partner, and the patient
D) All EMS providers participating in patient care on the call

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27) What is the chief complaint in the following narrative?
The pt. stated he had chest pain x 2 days before calling EMS. Pt. denies SOB. Vitals: BP 90/50,
respirations labored with retractions, HR 44. Rx: O2 and atropine 0.5 mg IVP. Upon arrival, the
pt. reported feeling better.
A) Chest pain
B) Hypotension
C) Labored respirations
D) Shortness of breath

28) The narrative approach that focuses only on the areas involved in the current illness or injury
is the ________ approach.
A) Body systems
B) Toe-to-head
C) Focused exam
D) Head-to-toe

29) “The 45-year-old patient had CP and was complaining of leg and arm pains.” In this
example, the abbreviation CP stands for:
A) Cerebral palsy
B) Cerebral perfusion
C) Chest pain
D) Unable to determine

30) Which of the following situations poses an even greater risk of liability to the paramedic than
patient refusal of care?
A) Denying transport to an apparently stable patient who insists he needs an ambulance
B) Transporting minors, with or without their consent
C) Transporting a mentally incompetent individual against his wishes
D) Having the patient who wants to refuse speak directly with a medical control physician

31) In filling out your prehospital care report (PCR), you want to document that your patient had
a laceration to his right hand secondary to a fall. How would you abbreviate “secondary to?”
A) 2°
B) 2/
C) 2@
D) 2nd

32) Which is the most important reason for NOT trying to complete the PCR during the ride to
the hospital?
A) Your time is better spent performing ongoing assessments.
B) You must communicate with the medical control physician.
C) There is an increased chance of error.
D) The ride is bumpy and the chart will be illegible.

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33) Instead of using the words heart attack, the paramedic could use the abbreviation:
A) AMI
B) CP
C) AHA
D) HA

34) Which words are spelled incorrectly in the following narrative?

Pt. is a 53 y/o male with pain to the upper thoracks and neck 2- to past history. Pt. has a history
of a heart attack and takes KCl, HCTZ, and aspirin.
1. Thoracks
2. Heart attack
3. Aspirin
4. History
A) 1 only
B) 1 and 3 only
C) 3 only
D) None of the above

35) Which of the following is used to quickly record patient vital information in mass-casualty
incidents?
A) A piece of 2-inch tape on the patient’s forehead
B) Prehospital care reports
C) MCI narratives
D) Triage tags

36) An accurate prehospital care report includes all of the following, EXCEPT:
A) Proper acronyms
B) Approved abbreviations
C) Best-guessed times
D) Proper spelling

37) All of the following are part of the standard patient documentation narrative, EXCEPT a(n):
A) Assessment/management plan
B) Subjective narrative
C) Financial assessment
D) Objective narrative

38) The narrative format that focuses on immediate management of a variety of patient problems
is called:
A) Body systems
B) SOAP
C) Patient management
D) Objective-subjective

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39) Writing false or malicious words intended to damage a person’s character is called:
A) Character assassination
B) Bad faith
C) Slander
D) Libel

40) The call incident approach for narrative writing emphasizes all of the following, EXCEPT:
A) How the incident occurred
B) Absolute chronological order
C) Surrounding circumstances
D) Mechanism of injury

41) Which of the following would be most useful for paramedics to carry with them as an aid to
proper documentation?
A) Pocket-sized thesaurus
B) Copy of previous charts
C) Pocket-sized medical dictionary
D) Quality assurance policy

42) Why do patient refusals warrant more thorough documentation than typical EMS calls?
A) Additional witnesses must be quoted.
B) The patient is usually not competent.
C) There is more time available before the next assignment.
D) The potential for abandonment charges is greater.

43) Why should the PCR be completed immediately after the call?
A) The medical control physician must sign it.
B) You must get back in service.
C) The information is fresh in your mind.
D) The receiving facility demands it.

44) Which of the following statements is inappropriate for a prehospital care report?
A) The patient had trouble walking.
B) The patient’s appearance indicated a lack of self-care.
C) The patient was intoxicated.
D) The patient stated, “I feel fine.”

45) You are allowed to share the information in patient charts with all of the following,
EXCEPT:
A) Law enforcement officials, in specific situations
B) Third-party billing companies
C) Medical professionals providing continuing care
D) Other paramedics not on the call

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46) To correct an error on the PCR, the paramedic should:
A) Make it a habit to use erasable ink so mistakes can be completely erased
B) Cross it out with one line and initial it
C) Block it out completely
D) Use correction fluid matching the paper color of each copy of the PCR

47) Use of prehospital care reports for quality improvement is an example of their ________ use.
A) Medical
B) Administrative
C) Patient care
D) Legal

48) Which of the following is the paramedic’s interpretation of the patient’s problem?
A) Chief complaint
B) Subjective opinion
C) Patient complaints
D) Field diagnosis

49) Seeking and recording pertinent negatives demonstrates which of the following?
A) Charting by exception
B) Thoroughness of your examination
C) Thoughtfulness of your care
D) Use of the PERT-NEG format

50) The standard charting abbreviation for nitroglycerin is:

A) NTG
B) NGT
C) Nitro
D) N2O

51) What is the patient’s heart rate in the following narrative?

The pt. complained of CP x 2 days before calling EMS and is now also c/o SOB. Vitals BP
90/50, labored with retractions. Treated with O2 and atropine. Upon arrival, the pt. reported
feeling better.
A) 50
B) 90
C) 40
D) Cannot be determined

52) Which of the following best describes why abbreviations and acronyms can cause confusion
and problems?
A) They are not universally accepted by all EMS agencies.
B) Nursing uses a different set of abbreviations and acronyms.
C) Some abbreviations and acronyms can have multiple meanings.
D) Physicians use a different set of abbreviations and acronyms.

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53) The ultimate responsibility for documentation belongs to the:
A) Agency’s administration
B) Paramedic writing the PCR
C) Medical control physician
D) Receiving nurse

54) One common pattern for organizing a narrative report is identified by the mnemonic:
A) CHART
B) OPRST
C) SAMPLE
D) DCHART-E

55) Careful, thorough documentation has the effect of ________ frivolous lawsuits.
A) Eliminating
B) Defeating
C) Discouraging
D) Encouraging

56) Under what circumstances should paramedics try to hide charting errors?
A) Always
B) When directed to by a supervisor or superior officer
C) When a lawsuit is probable
D) Never

57) The objective narrative portion of documentation contains information on the:

A) History of the present illness
B) Current health status
C) Chief complaint
D) Physical exam

58) The unofficial language used by a particular group or profession is known as ________ and
can be confusing when included on a PCR.
A) Terminology
B) Semantics
C) Slang
D) Jargon

59) Which of the following words is an example of proper medical terminology?

A) Belly
B) Thorax
C) Jawbone
D) Chest

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60) Why is it important for billing companies to have complete PCRs?
A) They can decide what to bill for.
B) They require all information for accurate billing.
C) They provide quality assurance audits as part of their service.
D) They are required by law to collect the complete PCR.

61) Who would be held MOST responsible if poor prehospital documentation results in
inappropriate continuing medical care?
A) The patient, if he was uncooperative
B) The paramedic who wrote the document
C) The paramedic agency and its medical director
D) The physician who ordered the continuing medical care

62) If a legal case is brought against you, your best defense in court is usually:
A) The dispatch log
B) Your immediate recollection of events
C) A complete and accurate PCR
D) Your partner’s corroborating testimony

63) Your patient is complaining of respiratory distress. In ruling out congestive heart failure, the
absence of swollen ankles would be a:
A) False positive finding
B) False negative finding
C) Pertinent negative finding
D) True positive finding

64) The standard charting abbreviation for Tylenol is:

A) ASA
B) Acet
C) APAP
D) Amp

65) When using a prehospital care report for research or quality assurance, you should block out
the:
A) Patient’s identifying information
B) Times
C) Paramedics’ names
D) Treatments rendered

66) Patient and bystander quotes belong in the ________ section.

A) Objective narrative
B) Subjective narrative
C) Assessment/management plan
D) Quotation

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