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A comprehensive set of questions and answers related to prehospital care documentation and patient assessment, covering key aspects of emt training. It explores topics such as accurate documentation, patient refusal of care, objective and subjective findings, and the importance of detailed reporting. Valuable for emt students and professionals seeking to enhance their understanding of proper documentation practices and patient assessment techniques.
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An alert and oriented male patient with chest discomfort refuses treatment and transport to the hospital. He is angry with his family for calling 911 and refuses to sign the refusal of care form despite several requests. Which of these is your next best action? - ANSWER Have a family member sign as a witness to the father's refusal
What would be considered an objective patient assessment finding? - ANSWER Blood pressure 114/68 mmHg
You document the following on the prehospital care report: "c/o H/A with associated n/v; pt. denies existing CNS problems or history of the same; states positive history of AAA and ETOH abuse." Regarding this narrative, which interpretation would be most accurate? - ANSWER The patient has a headache
You have transported a confused 46-year-old male who overdosed on an unknown drug to a busy emergency department. After giving an oral report to the ED nurse, your partner informs you that he wants to hurry back to the station so that he can watch the end of the football game; therefore, he is going to complete the patient care report (PCR) at a later time. How should you respond? - ANSWER "If you do not complete and leave the PCR, the ED staff may not otherwise have access to information contained in the PCR."
When getting a refusal from a patient who does not want the services of EMS providers, it is critical for the EMT to complete which step - ANSWER Have the patient sign and date the refusal form
A patient states that he has suffered from chronic neck pain ever since an accident. Further, he states that he is filing a lawsuit against the EMTs since they failed to put a cervical collar on him at the time; in his eyes, this is the reason he has daily neck and back pain. The EMT can remember the incident well and remembers putting a collar on the patient. As such, his best defense would be: - ANSWER Written documentation of collar placement on the PCR
Two days after a call, you realize that you forgot to document that you checked a patient's blood glucose prior to him refusing transport and signing the
refusal form. At that time, you did contact medical direction and provide this information to the doctor, prior to him authorizing the patient to refuse. What is now your best course of action? - ANSWER Add an addendum to the report with the correct information, the current date, and the EMT's initials
Just before the end of their shift, EMTs transported a young male who bystanders state "passed out" and then had a seizure. Now, an hour later, the patient has been stabilized and the physician asks the nurse if she knows what the seizure looked like. To easily answer this question. she would: - ANSWER Check the prehospital care report
You are involved in a lawsuit over a stabbing that occurred six months ago. Since you work in a busy EMS system and some time has passed, your recollection of the incident in spotty. In this situation, your best means of remembering what occurred would be to - ANSWER Review the prehospital care report
Last week, on a computer-generated report, you accidentally documented that a patient suffered from hypertension when, in fact, he did not. Unfortunately, the report has been locked by the computer and cannot be changed; however, it can be printed. Your first action would be to: - ANSWER Print the report and draw a line through the error
A patient with asthma is using his inhaler TID and prn. You would recognize that: - ANSWER The patient uses an inhaler at least three times a day
When completing a paper-based prehospital care report, you accidentally write that a laceration was on the left side of a patient's face when it was actually on the right side of the face. Correcting this mistake would include which step? - ANSWER Draw a single line through the term "left" and write the word "right" next to it
Immediately after giving a prehospital care report to the nurse in the emergency department, dispatch informs you that there are no more ambulances available and you
You are reviewing a prehospital care report (PCR) and note the following entry: "Pt. took PCN TID PO for 5 days." You would interpret this as the patient took: - ANSWER Penicillin was taken orally three times a day for five days straight
When asked, an alert and oriented 44-year-old male tells you that he called 911 because "my chest is hurting." The man is also sweating and feels as if he is going to vomit. He has a history of high blood pressure and states that this pain "feels just like my heart attack two years ago." His pulse is 88 beats per minute, respirations are 18 breaths per minute, and blood pressure is 156/92 mmHg. On room air, he has an oxygen saturation level of 95 percent. Based on this information, how would you document his chief complaint on the patient care report? - ANSWER "My chest is hurting."
What would be the best reason for a policy that requires all crew members to synchronize their watches with dispatch at the beginning of each shift? - ANSWER Promotes accurate system-wide time record keeping throughout the shift
Which item is included in the U.S. Department of Transportation minimum data set? - ANSWER Vital signs and skin condition
The medical director for your service has put you in charge of designing a new prehospital care report form. He states that it must contain the "minimum data set" as set forth by the U.S. Department of Transportation. In completing this task, you realize that incorporating these data into your report form will: - ANSWER Allow easier comparison of specific EMS data between various types of emergency systems
A patient states that he has had a headache located in his forehead for three days. The EMT should recognize and document this piece of information as a(n): - ANSWER Subjective finding
While moving a 67-year-old male who complains of dizziness from his residence on the stretcher, you stumble backward and knock a vase from a table, causing it to break. The patient and family are very upset with the damage. In the process, you hurt your ankle and are having a hard time walking. When completing the prehospital care report (PCR), what should be included? - ANSWER The patient's insurance or billing information
Which statement describes an advantage of computerized documentation? - ANSWER Large amounts of data can be stored and retrieved much more easily than with handwritten PCR'S
A patient tells you that he has been feeling "very weak" for the past three days. Using the SOAP charting format, this information would be included under which heading? - ANSWER S: Subjective
Which patient who refuses treatment should still be transported to the hospital? - ANSWER A 29-year-old female who attempted to cut her wrists earlier during a failed suicide attempt, but now changes her story and states it was an accident
After oxygen therapy, the patient's SpO2 improves from 90% to 99%. Using the CHEATED method of documentation, this information would be placed in which category? - ANSWER E: Evaluation
You have been called to the house of a patient with altered mental status. You encounter a 41-year-old male who exhibits slurred speech, an unsteady gait, and an odor resembling that of alcohol on his breath. His wife states that he is an alcoholic and needs help to get better. When documenting this information, which statement would be best? - ANSWER Per wife-patient has alcoholic history
Your partner states that he is the "world's worst speller" and has great difficulty using medical terms. How would you respond to this statement? - ANSWER "Use everyday language if you are unsure of how to apply or spell a medical term."
Which statement shows an accurate understanding of the legal aspects of the prehospital care report (PCR)? - ANSWER "The PCR may be subpoenaed even if the lawsuit centers on alleged negligence that occurred in the emergency department."
A patient care report reads: "c/o chest pain with associated DOE; PMH of IDDM." Regarding this description, which interpretation is most accurate? - ANSWER The patient has diabetes