Chapter 4

44問 • 11ヶ月前

問題一覧

What would be considered an objective patient assessment finding?

Blood pressure 114/68 mmHg

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?

The patient's insurance or billing information

Which item is included in the U.S. Department of Transportation minimum data set?

Vital signs and skin condition

A nauseated patient with fever and abdominal pain states that he has not vomited. Which description best represents how that fact should be documented?

As a pertinent negative

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?

S: Subjective

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?

E: Evaluation

Which item would the EMT place in the administrative information section of the prehospital care report?

BLS Unit 204; Incident # 67-8971-90

You have placed a 67-year-old female patient on low-concentration oxygen with a nasal cannula. Under which section of the prehospital care report (PCR) would you document this information?

Treatment

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?

My chest is hurting."

An intoxicated patient will not leave the oxygen mask on. What would be the most appropriate way to document this behavior on the prehospital care report?

The patient continually removes the oxygen mask despite continued verbal redirection and reapplication.

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):

Subjective finding.

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?

Draw a single line through the term "left" and write the word "right" next to it.

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?

Add an addendum to the report with the correct information, the current date, and the EMT's initials.

What is meant by the "prudent layperson" standard?

A method to help insurance companies determine if they will pay for an ambulance transport or not.

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?

Have a family member sign as a witness to the father's refusal.

After a patient, who is short of breath, signs a refusal of service form, which statement would be appropriate prior to leaving the residence?

If you change your mind at any time and want to be transported to the hospital, call 911 again."

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?

Have the patient sign and date the refusal form.

In order to better assure that Medicare will pay for the transport of an elderly patient with weakness, what is one component that the EMT should be certain to include in the PCR?

Justification as to why the patient could not be transported by a lesser means of transport other than an ambulance

You have transferred care of a 21-year-old woman who overdosed on an unknown drug. For the patient, which best describes who is permitted access to the prehospital care report (PCR)?

The healthcare provider assuming care of the patient

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 Emergency Department (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?

If you do not complete and leave the PCR, the ED staff may not otherwise have access to information contained in the PCR which may impact patient care."

Which statement regarding a patient care report (PCR) is accurate?

Aside from providing a record of the care given, the PCR also may be used for education and research."

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:

Allow easier comparison of specific EMS data between various types of emergency systems.

Which statement describes an advantage of computerized documentation?

Large amounts of data can be stored and retrieved much more easily than with handwritten PCRs.

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?

Use everyday language if you are unsure of how to apply or spell a medical term."

You are reviewing a prehospital care report (PCR) and find this entry: "Pt. took PCN TID PO for 5 days." You would interpret this as the patient took:

Penicillin was taken orally three times a day for five days straight.

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?

Promotes accurate system-wide time record keeping throughout the shift

A prehospital care report reads: "GSW to LLQ." Based on this, you should recognize that the patient sustained a(n):

Gunshot to the lower left abdomen.

A patient care report reads: "c/o fall with (R) hip pain; FROM to (R) low. ext." Based on this, you should recognize that the patient's:

Right leg can be moved normally.

A patient care report reads: "PMH includes ESRD and (+) DNR; (+) ASA pta of EMS." Regarding this description, which interpretation is most accurate?

The patient has kidney disease.

A patient care report reads: "c/o CP with associated DOE; PMH of IDDM, CAD, & ARF." Regarding this description, which interpretation is most accurate?

The patient has diabetes.

Your protocol reads: "O2 via NC prn if symptomatic for CP / SOB & SpO2 < 94%." To follow this order, you should perform which action?

Consider oxygen for a patient complaining of chest pain if the SpO2 is 92%.

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 must immediately leave the hospital to cover another portion of the county. Since your service uses a computerized documentation system and there is no time to complete your report, your best course of action should be to:

Complete an abbreviated transfer-of-care report.

You have been called for a 2-year-old female with an arm injury. The child presents with deformity and bruising to her left forearm. When asked, the mother states that the child fell from the bed, but the father states that his daughter fell down the stairs. Given the inconsistent stories, you are suspicious of child abuse. Which narrative would be most appropriate when documenting this situation?

Patient fell off of bed injuring left arm—per mother; patient fell downstairs injuring left arm—per father."

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?

Per wife—patient has alcoholic history

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:

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:

Review the prehospital care report.

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 placing a cervical collar on the patient. As such, his best defense would be:

Written documentation of cervical collar placement on the patient care report (PCR).

The medical director states that it seems as if the number of patients suffering from shortness of breath with a history of congestive heart failure (CHF) has increased. She adds that she is thinking about modifying the protocols, but first must know the number of patients seen with this condition over the past year. To best determine the number of patients treated for this condition, you would:

Review the previous prehospital care reports.

You document this statement 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?

The patient has a headache.

Consider this narrative from a patient care report: "pt. transported 3 days ago for suspected STEMI; pt. currently denies CP and SOB; PMH of HTN and CAD; pt. currently in NAD." Which of these interpretations is most accurate?

The patient has heart problems.

Consider this narrative from a patient care report: "pt. restrained passenger involved in 2 car MVC; c/o left lower leg pain rated 2/10; LOC is A/O to person, place, time, and event; BBS +; abd. Soft with tenderness LLQ; hx of NIDDM with am glucose level of 133 mg/dL." Which of these interpretations is most accurate?

The patient's lungs sounds are present bilaterally.

Last week, you accidentally documented on a patient care report that a patient suffered from hypertension when, in fact, he did not. Your first action to remedy this oversight would be to:

Obtain the original and draw a line through the error.

A patient with asthma is using his inhaler TID and prn. You would recognize that:

The patient uses an inhaler at least three times a day.

A pertinent negative would be illustrated by:

Nausea without vomiting."

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