Documentation (Powerpoint) - 60 Mins -EMT-b

25 Questions | Total Attempts: 247

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Documentation Quizzes & Trivia

Please place your FD or EMS Agency Name and your complete name in the name box.


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