Documentation (Powerpoint) - 60 Mins -EMT-b
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- 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
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