Documentation (Powerpoint) - 60 Mins -EMT-b

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| By Medic2690
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Medic2690
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Quizzes Created: 33 | Total Attempts: 65,589
Questions: 25 | Attempts: 304

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Documentation Quizzes & Trivia

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Questions and Answers
  • 1. 

    Documentation preserves basic patient information. True or False

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Documentation is an essential part of healthcare as it preserves basic patient information. This information includes the patient's medical history, current conditions, medications, allergies, and any other relevant details. By accurately documenting this information, healthcare providers can have a comprehensive view of the patient's health, which aids in making informed decisions about their care. Additionally, documentation ensures continuity of care, as different healthcare professionals can access and review the patient's information. Therefore, it is crucial for healthcare providers to maintain accurate and up-to-date documentation to provide safe and effective care to their patients.

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  • 2. 

    Documentation records changes in patient condition. True or False

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Documentation is a crucial aspect of healthcare that involves recording all relevant information about a patient's condition, including any changes. This documentation serves as a comprehensive record of the patient's medical history, treatment, and progress. By accurately documenting changes in a patient's condition, healthcare professionals can track their health status, identify trends, and make informed decisions about their care. Therefore, it is true that documentation records changes in patient condition.

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  • 3. 

    Documentation justifies treatment. True or False

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    The given statement is true. Documentation plays a crucial role in justifying the treatment provided to a patient. It serves as evidence of the medical history, diagnosis, and the treatment plan followed. Proper documentation ensures transparency, accountability, and helps in legal and reimbursement purposes. It also facilitates effective communication among healthcare providers, ensuring continuity of care. Therefore, documentation is essential in justifying the treatment provided.

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  • 4. 

    Documentation hinders the continuity of care. True or False

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    Documentation actually helps in maintaining the continuity of care. It provides a detailed record of the patient's medical history, treatment plans, medications, and other important information. This helps healthcare providers to have a comprehensive understanding of the patient's condition and make informed decisions regarding their care. Documentation also facilitates effective communication between different healthcare professionals involved in the patient's treatment, ensuring that there is a seamless transition of care. Therefore, the statement that documentation hinders the continuity of care is false.

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  • 5. 

    Documentation satisfies regulatory requirements. True or False

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Documentation plays a crucial role in satisfying regulatory requirements. It helps organizations demonstrate compliance with laws, regulations, and industry standards. By documenting their processes, procedures, policies, and controls, organizations can provide evidence of their adherence to regulatory requirements. This documentation can be used for audits, inspections, and legal purposes. Therefore, it is true that documentation satisfies regulatory requirements.

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  • 6. 

    Documentation provides data for quality control. True or False

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Documentation provides data for quality control because it serves as a record of the processes, procedures, and standards that should be followed in order to ensure quality. By referring to the documentation, quality control teams can compare the actual practices with the documented ones, identify any deviations or non-compliance, and take corrective actions to maintain or improve the quality of the product or service. This data from documentation helps in monitoring and controlling the quality of the processes and outputs.

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  • 7. 

    Documentation protection for EMS personnel. True or False

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    EMS personnel often deal with sensitive medical information and personal data of patients. Documentation protection is crucial to ensure the privacy and confidentiality of this information. By implementing proper security measures and protocols, EMS personnel can safeguard the documentation from unauthorized access, loss, or damage. This includes secure storage, restricted access, encryption, and adherence to privacy laws and regulations. Therefore, it is true that documentation protection is essential for EMS personnel.

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  • 8. 

    Documentation is a reflection of good patient care. True or False

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Documentation is an essential part of providing good patient care as it helps in maintaining accurate and complete records of the patient's condition, treatment, and progress. It allows healthcare professionals to have access to relevant information, make informed decisions, and ensure continuity of care. Proper documentation also promotes effective communication among the healthcare team, reduces the risk of errors or omissions, and provides legal protection. Therefore, the statement "Documentation is a reflection of good patient care" is true.

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  • 9. 

    Which are characteristics of a good medical record?

    • A.

      Accurate

    • B.

      Complete

    • C.

      Legible

    • D.

      Free of extraneous information

    • E.

      All the above

    Correct Answer
    E. All the above
    Explanation
    A good medical record should possess several characteristics. First, it should be accurate, meaning that the information recorded is correct and true. Second, it should be complete, containing all necessary and relevant information about the patient's medical history and treatment. Third, it should be legible, ensuring that healthcare professionals can easily read and understand the information. Finally, a good medical record should be free of extraneous information, meaning that it only includes relevant details and avoids unnecessary clutter. Therefore, the correct answer is "All the above" as all of these characteristics are important for a good medical record.

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  • 10. 

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

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Documenting facts and observations is indeed a good way to ensure the accuracy of documentation. By recording information based on actual facts and direct observations, the documentation becomes more reliable and trustworthy. This approach helps to avoid assumptions, biases, or subjective interpretations that could potentially distort the information being documented. Therefore, it is important to rely on facts and observations when creating documentation to maintain its accuracy.

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  • 11. 

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

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    Documenting speculations about a patient or incident is not a good way to keep documentation accurate. Speculations are based on assumptions and guesses rather than factual information, which can lead to misinformation and potential harm to the patient. It is important to document only verified information and facts to ensure accuracy and reliability in healthcare documentation.

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  • 12. 

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

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Double-checking numerical entries is a good way to ensure the accuracy of documentation. By verifying the numerical data entered, errors can be caught and corrected before they cause any problems. This practice helps maintain the integrity of the documentation and avoids potential mistakes or misunderstandings that could arise from incorrect numerical information.

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  • 13. 

    Recheck spelling is a good way to keep your documentation accurate. True or False

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    Rechecking spelling is a good way to ensure accuracy in documentation. By reviewing the spelling of words, it helps to eliminate any potential errors or typos that may have been made during the initial writing process. This can enhance the overall quality and professionalism of the documentation, making it easier for readers to understand and follow. Therefore, the statement that rechecking spelling is a good way to keep documentation accurate is true.

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  • 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

    Correct Answer
    E. All the above
    Explanation
    To make documentation complete, it is important to include all requested information and if any requested information does not apply, it should be noted as "not applicable" or "N/A". Additionally, it is necessary to include at least two sets of vital signs on every patient. Failure to document implies failure to consider, so it is crucial to ensure that all the above steps are followed to make the documentation complete.

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  • 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

    Correct Answer
    D. All the above
    Explanation
    It is important that your documentation be legible because if you cannot read the report, you may be unable to determine what happened. Additionally, documents presented in court must "speak for themselves," and if a document cannot be deciphered, the jury has the right to ignore it altogether. Therefore, all of the above reasons highlight the importance of legible documentation.

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  • 16. 

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

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    It is important to leave a copy of the report with the patient at the receiving hospital for several reasons. Firstly, it ensures that the patient has access to their medical information, which can be crucial for their ongoing care and treatment. Secondly, having a copy of the report allows the patient to review and understand the information provided, which can empower them to make informed decisions about their health. Lastly, it serves as a record for the patient, providing them with a comprehensive history of their medical journey.

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  • 17. 

    The person who drove the ambulance must write the patient report. True or False

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    The statement is false because the person who drove the ambulance is not necessarily responsible for writing the patient report. The person who attended to the patient or provided medical care would typically be the one responsible for documenting the patient's condition and treatment. The driver's role is primarily focused on safely transporting the patient to the hospital or medical facility.

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  • 18. 

    All personnel who participated in care should review the report. True or False

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    All personnel who participated in care should review the report. This statement is true because it is important for all individuals who were involved in providing care to review the report. This ensures that everyone is aware of the information contained in the report and can address any issues or concerns that may arise. By reviewing the report, personnel can also identify areas for improvement and make necessary changes to enhance the quality of care provided.

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  • 19. 

    Report all facts and observations to nursing staff. True or False

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    The correct answer is true because reporting all facts and observations to the nursing staff is an important part of providing quality patient care. It allows the nursing staff to have a complete picture of the patient's condition and make informed decisions about their care. By reporting all facts and observations, the nursing staff can identify any changes or potential concerns that may require further assessment or intervention. This helps ensure the safety and well-being of the patient.

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  • 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

    Correct Answer
    E. A and B only
    Explanation
    The correct answer is A and B only because it is stated in the question that if a diagnostic impression must be stated, it should be done within the scope of your training and include the observations that led to the impression. There is no mention of Episode 12 of ER in the question, so it is not included in the correct answer.

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  • 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

    Correct Answer
    A. True
    Explanation
    When a monitor is placed on a patient to record their EKG (electrocardiogram), it is important to have a hard copy of the EKG accompany the report. This is because the monitor may not always accurately display the EKG in real-time, and having a hard copy allows for a more detailed analysis and comparison. Additionally, a hard copy can be used for documentation and reference purposes. Therefore, it is true that a hard copy of the EKG should accompany the report when a monitor is used on a patient.

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  • 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

    Correct Answer
    E. All the above
    Explanation
    The report on MVCs should include all of the mentioned information, including the type of collision, degree of damage to vehicles, location of patients, and use of seatbelts. This comprehensive information is necessary to provide a complete and accurate assessment of the accident and its effects.

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  • 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

    Correct Answer(s)
    A. Discharge from nose and ears
    B. Cervical pain, muscle spasm, tenderness, deformity
    C. Paresthesias
    D. Altered motor function
    E. Altered sensory function
    Explanation
    This answer is correct because it includes all the possible signs and symptoms that should be reported in a head injury. Discharge from the nose and ears can indicate a skull fracture or damage to the brain. Cervical pain, muscle spasm, tenderness, and deformity can suggest injury to the neck or spinal cord. Paresthesias (abnormal sensations) may indicate nerve damage. Altered motor function and altered sensory function can be signs of brain injury or nerve damage. Therefore, all of these symptoms should be assessed and reported in a head injury.

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  • 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

    Correct Answer
    D. All the above
    Explanation
    The correct answer is "All the above". This means that all the options mentioned in the question are correct. The chest injuries report should include the position of the trachea, the status of neck veins, breath sounds, and heart sounds. Additionally, it should also mention the presence or absence of crepitus, subcutaneous air, and paradoxical movement of the chest wall.

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  • 25. 

    On extremity injuries report …

    • A.

      Distal skin color and temperature

    • B.

      Presence or absence of: Distal pulses, Motor function and Sensory function

    Correct Answer(s)
    A. Distal skin color and temperature
    B. Presence or absence of: Distal pulses, Motor function and Sensory function
    Explanation
    The given answer is a list of factors that should be reported on extremity injuries. These factors include distal skin color and temperature, as well as the presence or absence of distal pulses, motor function, and sensory function. These indicators are important in assessing the blood flow, nerve function, and overall health of the injured extremity.

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