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Flashcards in DOCUMENTATION HW Deck (30)
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1

Which of the following data would a state EMS office be the LEAST likely to require an EMS agency to report?
Choose one answer.
A. Call volume
B. Types of calls
C. Patient gender
D. Patient outcome

C

2

Which of the following statements contains objective and subjective information?
Choose one answer.
A. “The patient's behavior was consistent with alcohol intoxication.”
B. “The patient's pulse was rapid and weak and he was diaphoretic.”
C. “The patient's wife stated that he began feeling ill a few hours ago.”
D. “The patient appeared confused and stated that he had a headache.”

D

3

Blepharospasm is defined as spasm of the:
Choose one answer.
A. eyelids.
B. jaw muscles.
C. gallbladder.
D. wrist joint.

A

4

Data collected from the state EMS office for the purpose of research would likely NOT include:
Choose one answer.
A. patient outcomes.
B. the nature of all calls.
C. average cost per call.
D. call volume per month.

C

5

HIPAA mandates that:
Choose one answer.
A. a patient's personal information must be shared with the patient's immediate family members.
B. patient information shall not be shared with entities or persons not involved in the care of the patient.
C. a penalty will be imposed for any release of any portion of a patient's personal information to any entity.
D. patient information can only be shared with the receiving physician in the emergency department.

B

6

Prior to submitting a patient care report to the receiving hospital, it is MOST important for:
Choose one answer.
A. your partner to review the report to ensure accuracy.
B. the EMS medical director to review the report briefly.
C. the paramedic who authored the report to review it carefully.
D. the quality assurance team to review the report for accuracy.

C

7

Which of the following prefixes means “pertaining to a gland”?
Choose one answer.
A. chole-
B. aden(o)-
C. blast(o)-
D. arthro-

B

8

Most EMS agencies require a double signature system any time a:
Choose one answer.
A. medication that alters a patient's physiology is given.
B. patient's condition warrants diversion to a closer hospital.
C. patient is given more than one dose of any medication.
D. controlled substance is checked, used, discarded, or replaced.

D

9

When documenting a statement made by the patient or others at the scene, you should:
Choose one answer.
A. document the exact time that the statement was made.
B. include the statement in an addendum to your run report.
C. translate the statement into appropriate medical terminology.
D. place the exact statement in quotation marks in the narrative.

D

10

Additions or notations added to a completed patient care report by someone other than the original author:
Choose one answer.
A. may raise questions about the confidentiality practices of the EMS agency.
B. are generally acceptable, provided the additions are made by a paramedic.
C. are not legal and may result in criminal action against the original author.
D. must be initialed by the original author or the patient care report will be deemed null and void.

A

11

The MOST effective way to maintain your own knowledge of standard medical terminology is to:
Choose one answer.
A. read the patient care reports that your peers write.
B. memorize the standard terms used by your EMS system.
C. participate in a QA process that reviews patient care reports.
D. review the anatomy and physiology chapter of a textbook.

D

12

Which of the following is a significant benefit of electronic documentation?
Choose one answer.
A. The ability of the data to be shared between health care facilities
B. The elimination of the need for a narrative section
C. The use of drop-down boxes, which minimizes the possibility for errors
D. The ease with which it can be applied during mass-casualty incidents

A

13

If you receive another call before completing the patient care report accurately for the previous call:
Choose one answer.
A. you should submit what you have completed to the receiving facility.
B. pertinent details about the previous call may be omitted inadvertently.
C. your patient care report must be completed within 36 hours after the call.
D. you should ask the dispatcher to send another paramedic crew to the call.

B

14

Which of the following statements includes a pertinent negative?
Choose one answer.
A. “The patient complains of nausea but denies vomiting.”
B. “The patient rates his pain as an 8 on a scale of 0 to 10.”
C. “The possible smell of ETOH was noted on the patient.”
D. “The rapid head-to-toe exam revealed abrasions to the chest.”

A

15

Which of the following incident times is NOT commonly documented on the patient care report?
Choose one answer.
A. Time of primary assessment
B. Time of departure from the scene
C. Time of arrival at the hospital
D. Time of medication administration

A

16

If your response to a call for a traumatic injury is canceled, you should document:
Choose one answer.
A. that the patient refused medical treatment.
B. how the patient will get to a medical facility.
C. that the patient likely was not seriously injured.
D. the agency or person who canceled the response.

D

17

Which of the following laws or entities requires that a statement of medical necessity be clearly documented on a patient care report?
Choose one answer.
A. HIPAA
B. Medicare
C. Medicaid
D. State law

B

18

It is MOST important for the paramedic to exercise extreme care when using medical abbreviations because:
Choose one answer.
A. medical abbreviations change frequently.
B. many abbreviations have more than one meaning.
C. even correctly used abbreviations often cause confusion.
D. insurance companies do not pay if unapproved abbreviations are used.

B

19

The prefix trans- in “transcutaneous cardiac pacing” indicates that you are pacing ________ the skin.
Choose one answer.
A. beneath
B. within
C. around
D. across

D

20

In order to ensure that all recorded times associated with an incident are accurate, the paramedic should:
Choose one answer.
A. frequently glance at his or her watch.
B. radio the dispatcher after an event occurs.
C. document the time that each event occurs.
D. get a copy of the dispatch log after the call.

B

21

Which of the following is a subjective finding?
Choose one answer.
A. Pale, cool, clammy skin
B. Obvious respiratory distress
C. A complaint of chest pressure
D. Blood pressure of 110/60 mm Hg

C

22

An accurate and legible patient care report:
Choose one answer.
A. should be complete to the point where anyone who reads it understands exactly what transpired on the call.
B. is not possible on every call, especially if there is more than one patient or the patient is critically ill or injured.
C. is a relatively reliable predictor of the quality of care that the paramedic provided to the patient during the call.
D. provides immunity to the paramedic if the patient decides to pursue legal action against the paramedic.

A

23

Which of the following statements is LEAST descriptive when documenting the events of a cardiac arrest call on your patient care report?
Choose one answer.
A. “Followed ACLS protocols.”
B. “Intubated with a 7.5-mm ET tube.”
C. “Gave 1 mg of epinephrine at 1002.”
D. “Inserted 18-gauge IV in right forearm.”

A

24

The National Emergency Medical Services Information System (NEMSIS):
Choose one answer.
A. defines the scope of practice for all levels of EMS provider.
B. collects relevant data from each state and uses it for research.
C. is a nationwide billing system that any EMS provider can use.
D. defines the minimum data that must be collected on each call.

B

25

If the paramedic is unable to complete his or her patient care report before departing the emergency department, he or she should:
Choose one answer.
A. leave, at a minimum, the patient's name and age, but recognize that the physician will perform his or her own exam.
B. leave an abbreviated form with pertinent data with the receiving provider and complete the patient care report as soon as possible.
C. obtain the emergency department fax number and transmit the completed patient care report within 12 hours after delivering the patient.
D. advise the receiving provider that he or she will return to the emergency department with the completed patient care report within 24 hours.

B

26

The patient care report:
Choose one answer.
A. provides for a continuum of patient care upon arrival at the hospital.
B. is a legal document and should provide a brief description of the patient.
C. should include the paramedic's subjective findings or personal thoughts.
D. is only held for a period of 24 months, after which it legally can be destroyed.

A

27

When a competent adult patient refuses medical care, it is MOST important for the paramedic to:
Choose one answer.
A. ensure that the patient is well informed about the situation at hand.
B. contact medical control and request permission to obtain the refusal.
C. perform a detailed physical exam before allowing the patient to refuse.
D. obtain a signed refusal from the patient as well as a witness signature.

A

28

If a patient with decision-making capacity adamantly refuses treatment for an injury or condition that clearly requires immediate medical attention, the paramedic should:
Choose one answer.
A. request law enforcement assistance at once.
B. contact online medical control for guidance.
C. make other arrangements for patient transport.
D. ask the patient to sign a refusal of treatment form.

B

29

According to HIPAA, it is acceptable and permissible for hospitals to:
Choose one answer.
A. disclose information to a patient's family member, provided the family member has proper identification.
B. release patient information to the public health department, regardless of the patient's medical condition.
C. share information with the EMS providers about patient outcome for purposes of quality assurance and education.
D. release patient information to the media only if the hospital feels that the patient's condition may cause an epidemic.

C

30

Components of a thorough patient refusal document include:
Choose one answer.
A. assurance by the paramedic that the patient's ability to pay is of no concern.
B. notification of the patient's physician to apprise him or her of the situation.
C. documentation of a complete assessment, even if the patient refused assessment.
D. willingness of EMS to return to the scene if the patient changes his or her mind.

D