Documentation From Bradys Emergency Care 10 th Edition. 1. How should an error be corrected on an intact prehospital care report?

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Debra Caldwell
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1 Documentation From Bradys Emergency Care 10 th Edition 1. How should an error be corrected on an intact prehospital care report? A.) Scratch through, initial and correct B.) Draw a single line through, initial and correct C.) Draw a single line through and correct D.) Scratch through and correct 2. What is each individual box on the prehospital care report called? A.) Data component B.) Data set C.) Data element D.) Data fact 3. What should be noted when a patient refuses to sign a refusal-of-care form? A.) Contact medical direction B.) Document any witness names C.) Leave the form out of the filing D.) Forge the patient signature 4. Which time should be used when completing the prehospital care report? A.) Hospital B.) EMT-B's C.) Dispatch D.) Ambulance 5. Which type of error involves leaving out important information? A.) Commission B.) Omission C.) Confession D.) Obsession

) Data component B.) Data set C.) Data element D.) Data fact 3. What should be noted when a patient refuses to sign a refusal-of-care form? A.) Contact medical direction B.

2 6. Where should most prehospital care reports be stored for confidentially reasons? A.) Locked boxes B.) Hospital files C.) Public file cabinets D.) Insurance company 7. What should NOT be done when leaving a scene where the patient has refused care? A.) Encourage a call back if condition worsens B.) Explain other treatment alternatives C.) Appear annoyed for being called out for nothing D.) Arrange for a relative to remain 8. Which type of information may be collected for the report for administrative purposes? A.) Insurance B.) Research C.) Legal D.) Education 9. What is often used to record information on a single patient at a multiplecasualty incident? A.) Data entry form B.) Patient sheet C.) Triage tag D.) Situation mask 10. What are actions performed on the patient that were not appropriate? A.) Errors of omission B.) Errors of obsession C.) Errors of commission D.) Errors of confession

) Appear annoyed for being called out for nothing D.) Arrange for a relative to remain 8. Which type of information may be collected for the report for administrative purposes? A.) Insurance B.

3 11. Where can additional information be placed on the prehospital care report? A.) Patient data B.) Narrative C.) Run data D.) Check boxes 12. Which statement is true regarding prehospital care reports? A.) If it is written down, you may have done it B.) If it is not written down, you may have done it C.) If it is written down, you intended to do it D.) If it is not written down, you did not do it 13. What should be placed on a correction that is made to a prehospital care report that has been distributed to make it identifiable? A.) Initials B.) Stamp C.) Date D.) Flag 14. Which type of information should be included in the narrative section of the prehospital care report? A.) All subjective information B.) All objective information C.) No objective information D.) No subjective information 15. What is the narrative section of the prehospital care report is used to do? A.) Give detailed medical information B.) Paint a picture of their patient C.) Create a general impression of the patient D.) Give a personal account of emotional levels

) If it is written down, you intended to do it D.) If it is not written down, you did not do it 13.

4 16. Which legal reason is a rare occasion for the prehospital care report to be called upon? A.) Civil law proceedings for negligence B.) Patient was perpetrator of a crime C.) EMT-B being subject of lawsuit D.) Patient was victim of a crime 17. Which are examination findings that are negative? A.) Objective negatives B.) Negative negatives C.) Pertinent negatives D.) Subjective negatives 18. What should still be attempted when a patient refuses to be taken to the hospital? A.) Perform an assessment B.) Take them by force C.) Persuade them they are sick D.) Try to scare them into going 19. Which system is in place to ensure that reviews calls for conformity to current organizational standards? A.) Education and research B.) Legality C.) Administrative D.) Quality improvement 20. Which is the major portion of the prehospital care report? A.) Run data B.) Check boxes C.) Narrative D.) Patient data 21. What is a recent development in prehospital care reports? A.) Shading entry B.) Written report C.) Direct data entry D.) Computerized report

) Subjective negatives 18. What should still be attempted when a patient refuses to be taken to the hospital? A.) Perform an assessment B.) Take them by force C.) Persuade them they are sick D.

5 22. Which section of the prehospital care report contains the agency name and unit number? A.) Narrative B.) Patient data C.) Run data D.) Check boxes 23. What should NOT be included in the narrative section of the prehospital care report? A.) Pertinent negatives B.) Radio codes C.) Medical terminology D.) Standard abbreviations 24. Which is NOT considered a minimum piece of administrative information that is required on the prehospital care report? A.) Time of arrival at patient B.) Time of discharge C.) Time of arrival at destination D.) Time of incident report 25. What should be done when completing the prehospital care report if a patient becomes combative during transport and a second set of vitals cannot be taken? A.) Create a better reason B.) Make up a set of vitals C.) Document the happenings D.) Do not document any vitals

Which is NOT considered a minimum piece of administrative information that is required on the prehospital care report? A.) Time of arrival at patient B.) Time of discharge C.

07/14/2014 REVIEWED/REVISED: DATE TO BE REVIEWED: 01/31/2016 EMERGENCY MEDICAL SERVICES ELECTRONIC PATIENT CARE REPORT DOCUMENTATION - EPCR

POLICY NO: 701 DATE ISSUED: 08/2000 DATE 07/14/2014 REVIEWED/REVISED: DATE TO BE REVIEWED: 01/31/2016 EMERGENCY MEDICAL SERVICES I. PURPOSE: To define the use of standardized records to be used by Emergency