Documentation (Powerpoint) - 60 Mins -EMT-b

25 Questions | By Medic2690 | Last updated: Dec 13, 2012 | Total Attempts: 251

Questions

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Questions and Answers

1.

Documentation preserves basic patient information. True or False
- A.
  
  True
- B.
  
  False
2.

Documentation records changes in patient condition. True or False
- A.
  
  True
- B.
  
  False
3.

Documentation justifies treatment. True or False
- A.
  
  True
- B.
  
  False
4.

Documentation hinders the continuity of care. True or False
- A.
  
  True
- B.
  
  False
5.

Documentation satisfies regulatory requirements. True or False
- A.
  
  True
- B.
  
  False
6.

Documentation provides data for quality control. True or False
- A.
  
  True
- B.
  
  False
7.

Documentation protection for EMS personnel. True or False
- A.
  
  True
- B.
  
  False
8.

Documentation is a reflection of good patient care. True or False
- A.
  
  True
- B.
  
  False
9.

Which are characteristics of a good medical record?
- A.
  
  Accurate
- B.
  
  Complete
- C.
  
  Legible
- D.
  
  Free of extraneous information
- E.
  
  All the above
10.

Document facts, observations only are a good way to keep your documentation accurate. True or False
- A.
  
  True
- B.
  
  False
11.

Documenting speculations about patient or incident is a good way to keep your documentation accurate. True or False
- A.
  
  True
- B.
  
  False
12.

Double-checking numerical entries is a good way to keep your documentation accurate. True or False
- A.
  
  True
- B.
  
  False
13.

Recheck spelling is a good way to keep your documentation accurate. True or False
- A.
  
  True
- B.
  
  False
14.

Which are ways to make your documentation complete?
- A.
  
  Include all requested information
- B.
  
  If information requested does not apply, note “not applicable” or “N/A”
- C.
  
  Include at least two sets of vital signs on every patient
- D.
  
  Failure to document implies failure to consider
- E.
  
  All the above
15.

Why is it important that your documentation be legible?
- A.
  
  If you cannot read the report, you may be unable to determine what happened
- B.
  
  Documents presented in court must “speak for themselves”
- C.
  
  If a document cannot be deciphered, the jury has to right to ignore it altogether
- D.
  
  All the above
16.

A copy of the report must be left with the patient at the receiving hospital. True or False
- A.
  
  True
- B.
  
  False
17.

The person who drove the ambulance must write the patient report. True or False
- A.
  
  True
- B.
  
  False
18.

All personnel who participated in care should review the report. True or False
- A.
  
  True
- B.
  
  False
19.

Report all facts and observations to nursing staff. True or False
- A.
  
  True
- B.
  
  False
20.

If you must state a diagnostic impression ...
- A.
  
  Do so within the scope of your training
- B.
  
  Include the observations that led to the impression
- C.
  
  Make reference to Episode 12 of ER
- D.
  
  All the Above
- E.
  
  A and B only
21.

If you put a monitor on the patient, a hard copy of the EKG should accompany the report. True or False
- A.
  
  True
- B.
  
  False
22.

On MVCs, your report should list …
- A.
  
  Type of collision (head-on, roll-over, lateral impact, etc.)
- B.
  
  Degree of damage to vehicles
- C.
  
  Location of patients
- D.
  
  Use of seatbelts
- E.
  
  All the above
23.

On head injuries report presence/absence of …
- A.
  
  Discharge from nose and ears
- B.
  
  Cervical pain, muscle spasm, tenderness, deformity
- C.
  
  Paresthesias
- D.
  
  Altered motor function
- E.
  
  Altered sensory function
24.

On chest injuries report …
- A.
  
  Position of trachea
- B.
  
  Status of neck veins, breath sounds, heart sounds
- C.
  
  Presence or absence of Crepitus, Subcutaneous air and Paradoxical movement of chest wall
- D.
  
  All the above
- E.
  
  A and C only
25.

On extremity injuries report …
- A.
  
  Distal skin color and temperature
- B.
  
  Presence or absence of: Distal pulses, Motor function and Sensory function