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Flashcards in Ch.4 Deck (47)
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1

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

C.Chief complaint

2

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

B.Preparing bills

3

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 might refuse care.
B.A mechanical problem with his or her vehicle.
C.That the patient was not being honest.
D.That an elderly patient has been abused.

D.That an elderly patient has been abused.

4

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.Inaccurate
B.Incomplete
C.Confidential
D.Falsified

D.Falsified

5

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

B.Transient ischemic attack.

6

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

A.U.S. Department of Transportation

7

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 a child.
B.The patient died en route to the hospital.
C.The patient did not need EMS.
D.The patient was abused or neglected.

D.The patient was abused or neglected.

8

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

B.Using abbreviations you have developed

9

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.Objective information
B.Subjective information
C.Pertinent negatives
D.Patient medical history

B.Subjective information

10

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.Hybrid computer report
C.Traditional computer report
D.Traditional written report

D.Traditional written report

11

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

C.write it​ down."

12

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

A.Insurance information

13

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

D.​High-quality patient care

14

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

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

15

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

D.PCR

16

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

B.Assessment
(Subjective, Objective, Assessment, and Plan)

17

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

D.Use of accurate and synchronous clocks

18

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 creates more legible written reports.
B.It is the most common type of reporting system used today.
C.It is cheaper than paper reports.
D.It eliminates the need for the EMT to have a pen handy.

A.It creates more legible written reports.

19

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

D.plan.

20

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

A.Subjective interpretation about the treatment rendered

21

When utilizing the CHART mnemonic for​ documentation, where is the treatment provided to the patient​ documented?
A. A
B. R
C. H
D. T

B. R

22

Which one of the following situations would require a special​ report?
A.Childbirth
B.DOA
C.Medical direction contact
D.Gunshot wounds

D.Gunshot wounds

23

What does the medical abbreviation​ "CF" stand​ for?
A.Cystic fibrosis
B.Common finding
C.Collarbone fracture
D.Congestive failure

A.Cystic fibrosis

24

The​ patient's description of the mechanism of injury belongs in which one of the following​ sections?
A.Patient demographics
B.Administrative information
C.Vital signs
D.Patient narrative

D.Patient narrative

25

What is the value of documenting a pertinent negative on your​ PCR?
A.It demonstrates that the patient was alert.
B.The lack of the symptom is relevant to the assessment.
C.It shows you know to ask lots of questions.
D.It helps fill up the narrative portion of the form.

B.The lack of the symptom is relevant to the assessment.

26

The United States Department of​ Transportation's minimum data set for patient information gathered by the EMT​ includes:
A.capillary refill for patients less than three years old.
B.the​ patient's respiratory rate and effort.
C.systolic blood pressure for patients greater than one year old.
D.the​ patient's medical insurance information.

B.the​ patient's respiratory rate and effort.

27

Which of the choices is an advantage of the​ paper-based charting​ system?
A.The user typically has more freedom on the type of information​ entered, including writing style.
B.The user can just rip up a PCR they made an error​ on, and start a new one.
C.Since the paper system cannot connect to monitoring​ equipment, it is easier to use.
D.The paper system will not fail if the PCR is accidentally left out in the rain.

A.The user typically has more freedom on the type of information​ entered, including writing style.

28

Which of the following components is in the patient demographics section of the​ PCR?
A.Any allergies to medications.
B.The​ patient's family doctor.
C.The​ patient's chief complaint.
D.The​ patient's home address.

D.The​ patient's home address.

29

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

B.​High-quality patient care

30

In a​ multiple-casualty incident, the​ patient's name and chief complaint are recorded on​ a:
A.field note.
B.triage tag.
C.mobile data unit.
D.mini PCR.

B. triage tag