Chapter 17- Communication & Documentation

Which of the following best describes a repeater?

A. A two-way radio at a fixed site

B. A two-way radio that can be carried on a belt clip

C. A two-way radio that is mounted in a vehicle

D. A device that receives and amplifies a signal that must be carried over long distances

D. A device that receives and amplifies a signal that must be carried over a long distance

What of the following best describes a base station?

A. A​ two-way radio that can be carried on a belt clip

B. A device used to receive and then amplify transmissions that must be carried over long distances

C. A​ two-way radio mounted in a vehicle

D. A​ two-way radio at a fixed site

D. A two-way radio at a fixed site

Which of the following is the correct manner for making a correction on a paper copy of a patient care report?

A. Use typing correction fluid to cover up the error and write over it.

B. Draw a single line through the error and initial it.

C. Blacken out the entire error and draw an arrow to the correct information.

D. Get a credible witness to​ co-sign your patient care report.

B. Draw a single line through the error and initial it

Patient information includes all of the following except the:

A. patient's medications

B. patient's chief complaint

C. mechanism of injury

D. time the until was notified of the call

D. time the until was notified of the call

How many parts does a standard medical radio report have as described in your textbook?

A. 10

B. 12

C. 5

D. 8

B. 12

Which of the following is not an appropriate use of prehospital care report (PCR) information?

A. For referral to Alcoholics Anonymous or similar social services

B. To conduct research

C. To provide EMS personnel with education and quality assurance

D. For billing and insurance purposes

A. For referral to Alcoholics Anonymous or similar social services

Which of the following information does not need to be provided to the dispatcher?

A. Estimated time of arrival at the hospital

B. Which hospital you are transporting to

C. When you arrive at the hospital

D. When you depart from the hospital

A. Estimated time of arrival at the hospital

The portion of the patient care report in which the EMT writes his description of the patient's presentation, assessment findings, treatment, and transport information is called the:

A. narrative

B. deposition

C. Data set

D. text

A. narrative

Which of the following is a possible consequence of using medical terminology about which you are unsure of the meaning in your patient care report?

A. Embarrasssment

B. Loss of credibility

C. Negative impact on patient care

D. All of the above

D. All of the above

You are en route to the hospital with a 22-year-old male patient who has suffered a very embarrassing injury to his genitalia. Which method of contacting the receiving facility will afford the patient the most privacy?

A. Providing the receiving hospital with all information via a cell phone

B. Using the ambulance radio but not using the​ patient's name

C. Using the handheld radio

D. Using the ambulance radio but not providing details of the injury

A. Providing the receiving hospital with all information via a cell phone

Which of the following statement regarding eye contact with a patient is not true?

A. Failure to make eye contact may signal uneasiness to the patient

B. Eye contact is always appropriate

C. It shows you are attentive

D. It shows you are interested in the patient

B. Eye contact is always appropriate

Which of the following is not an appropriate way of dealing with a patient who does not speak the same language as you do?

A. Use a manual that provides translation

B. Use an interpreter

C. Contract dispatch for assistance in finding a translator

D. Avoid communicating with the patient so there is no misunderstanding of your intentions

D. Avoid communicating with the patient so there is no misunderstanding of your intentions

During your radio report to the hospital, which of the following pieces of information should NOT be relayed?

A. Patient's name

B. Patient's age

C. Patient's mental statue

D. Baseline vital signs

A. Patient's name

Which of the following is not considered a principle of proper radio usage in EMS?

A. Use plain English.

B. Speak as quickly as possible.

C. Make sure the radio is on before speaking.

D. Speak with your lips 2 to 3 inches from the microphone.

B. Speak as quickly as possible

You have an urgent transmission you need to make to the dispatch center. Which of the following is the appropriate way to communicate this?

A. Interrupt​ less-urgent radio traffic to get your message across.

B. Use the​ phrase, "Attention,​ attention, I have priority​ traffic."

C. Listen to the frequency first to avoid stepping on another transmission.

D. Speak loudly to convey the urgency of the message.

C. Listen to the frequency first to avoid stepping on another trasmission

You have received the following order from medical​ control: "Administer one tablet of nitroglycerin under the​ patient's tongue." Which of the following is the best​ response?

A. "Roger, order received."

B. ​"Order received. One nitroglycerin tablet under the​ patient's tongue."

C. ​"Clear. Will advise of any changes in​ patient's condition."

D. ​"Copy. Administering medication​ now.

B. "Order received. One nitroglycerin tablet under the​ patient's tongue."

Which of the following does not need to be documented regarding a patient refusal of​ treatment?

A. Any insulting remarks the patient made to you

B. That you advised the patient to call back if he changed his mind

C. That you informed the patient of the consequences of refusing care

D. ​Patient's mental status

A. Any insulting remarks the patient made to you

When you arrive at the receiving​ facility, the nurse asks your partner for a verbal report of the​ patient's condition. This is in addition to the radio report your partner gave to the hospital en route.​ Afterwards, you ask your partner why you must give a second verbal report and a written report to the receiving nurse. What is the best reason to provide both​ reports?

A. The nurse may be too busy to read the written report.

B. The nurse may have to perform critical interventions on the patient before you complete your written report.

C. The nurse may not have heard the first radio report.

D. The​ patient's condition may have changed since the first radio report.

B. The nurse may have to perform critical interventions on the patient before you complete your written report.

When giving a radio report to the hospital, which of the following would be the first patient- specific information provided?

A. The patient is having a heart attack

B. The patient is a 55-year-old male

C. The patient is complaining of chest pain

D. The patient has taken nitroglycerin

B. The patient is a 55-year-old male

You are on the scene of an unresponsive adult female patient. You find an empty pill bottle lying next to her bed. You look up the medication in your field guide and discover the medication is a powerful sedative. The prescription on the bottle is for the​ patient's husband, who is not present to answer questions about the medication. What should you​ do?

A. Do not document the empty pill bottle. It does not belong to the patient.

B. Document the empty pill bottle. It is obvious that she took the pills.

C. Do not document the empty pill bottle. You cannot prove that she took the pills and could lead the doctor to make a false diagnosis.

D. Document the empty pill bottle. It may provide important clues to the​ patient's condition.

D. Document the empty pill bottle. It may provide important clues to the patient's condition

Which of the following is not an appropriate statement for the EMT to make on a patient care​ report?

A. The patient complains of difficulty breathing.

B. The patient has a history of asthma.

C. The patient had wheezes that were audible without using a stethoscope.

D. The patient was having an asthma attack.

D. The patient was having an asthma attack

Which of the following is no appropriate for inclusion in the radio report to the receiving hospital?

A. Name of the​ patient's health insurance provider

B. Major past illnesses of the patient

C. Pertinent physical exam findings

D. Pertinent past illnesses

A. Name of the patient's health insurance provider

You have responded to a call at a government office building. One of the office workers became very upset during a fire drill and experienced an episode of difficulty breathing. As your partner is speaking with the​ patient, who is not sure she wants to be​ transported, an individual wearing civilian clothes approaches you and states she is a security guard in the building. She asks you for the​ "yellow copy" of your prehospital care report. Which of the following should you​ do?

A. Get permission from medical control

B. Provide the documentation if the individual shows proper information

C. State that you are unable to comply with the request due to patient confidentiality

D. Ask the patient if it is alright with her if you provide the individual with a copy of the prehospital care report

C. State that you are unable to comply with the request due to patient confidentiality

Which of the following is not appropriate to document on your patient care report

A. Patient's mental status

B. Patient's attitude

C. Patient's race

D. All should be documented

B. Patient's attitude

Which of the following best describes the position you should take when dealing with a cooperative patient who is sitting in a chair?

A. Sit on the floor at the patient's feet

B. Stand behind the patient's chair

C. Sit or kneel at the same level as the patient

D. Stand next to the chair

C. Sit or kneel at the same level as the patient

The QI manager calls your partner into his office after your shift. The QI managers pulls out your​ partner's EMS report on a call he ran last month on a​ 45-year-old driver of a​ single-vehicle motor vehicle collision. There were several empty beer cans in the​ patient's vehicle, and your partner detected an odor of alcoholic beverages on the​ patient's breath. The QI​ manager, however, critiques your partner about calling the patient an alcoholic and giving opinions in the report. He tells your partner to never write opinions in the EMS report. Your partner is confused because he is sure the patient was​ drunk, and he was actually arrested for suspicion of driving while intoxicated. Your partner believes his assessment is supported by facts and not just his opinion. How can you help your partner understand the QI​ manager's concerns?

A. The QI manager is afraid the patient will sue the EMS service for libel.

B. The patient is assumed to be innocent until proven guilty. He is not an alcoholic until he is convicted of drinking and driving by a court of law.

C. Documenting that the patient is an alcoholic is an unverifiable opinion of the patient that is not supported by available facts and could negatively influence other medical providers.

D. Calling the patient an alcoholic is not​ polite, even if it is true.

C. Documenting that the patient is an alcoholic is an unverifiable opinion of the patient that is not supported by available facts and could negatively influence other medical providers.

You are treating a patient with a possible fractured ankle. The patient appears to be in alot of pain and is uneasy. As you are getting ready to splint the patient's leg, he asks you if it is going to hurt. Which of the following is the best response?

A. "If you're stressed out like this, it's going to hurt a lot more."

B. "I will do my best, but it may hurt while we put the splint on."

C. "It doesn't matter, we have to do it anyways."

D. "Relax, this is not a painful procedure."

B. "I will do my best, but it may hurt while we put the splint on."

The Health Insurance Portability and Accountability Act (HIPAA) requires ambulance services to do all of the following except:

A. safeguard patient confidentiality

B. place patient care reports in a locked box

C. report child abuse

D. All of the above are required by HIPAA

C. report child abuse

Which of the following should not be included in a patient care report?

A. Patient's subjective statements

B. Chief complain

C. Radio codes

D. Pertinent negative findings

C. Radio codes

Two EMTs are on the scene of a behavioral call at a psychiatric facility. The medical personnel state that the patient had a psychotic episode and slashed his wrists. During the​ call, the patient claims to hear the voice of God and says that the voice is hurting his ears. The patient refuses to be transported to the emergency​ department, becomes​ combative, and bites one of the EMTs. Which of the following should not be documented on the EMS​ report?

A. The fact that the patient slashed her wrists

B. The fact that the patient was violent and bit the EMT

C. The fact that the EMT had an exposure incident

D. The fact that the patient hears voices

C. The fact that the EMT had an exposure incident

Which of the following should be placed in quotes in the patient care report?

A. Patient's expressed consent

B. Chief complaint

C. Mechanism of injury

D. List of patient's medications

B. Chief complaint

You are attempting to place a nonrebreather mask on a patient who is experiencing difficulty breathing. The patient is anxious and does not want the mask on his face. Which of the following is the best course of​ action?

A. Tell the patient the mask is for his​ benefit, and you will restrain him if necessary to place it on him.

B. Document that the patient was uncooperative and refused oxygen.

C. Explain the importance of​ oxygen, and ask the patient to at least try to leave the mask​ on, but assure him that if he​ can't tolerate​ it, you can try another method.

D. Tell the patient he will soon become unconscious without the​ mask, and then you will be able to place it on him.

C. C. Explain the importance of​ oxygen, and ask the patient to at least try to leave the mask​ on, but assure him that if he​ can't tolerate​ it, you can try another method

You suspect that a​ 6-year-old female patient with multiple bruises and a broken wrist was abused. The stepmother states the patient fell down the stairs. The patient is crying and sheepishly nods in agreement with the​ stepmother's statements. How should you document this situation in the patient​ report?

A. Document who you suspect caused the injuries in the narrative so that law enforcement has a record of the incident.

B. Document what was said as well as your opinion that the child was too afraid to tell the truth.

C. Document any pertinent information that was said by the stepmother and child exactly in quotations.

D. Document only the actual exam findings. Do not document anything that was said.

C. Document any pertinent information that was said by the stepmother and child exactly in quotations

Which of the following can be correctly noted as a chief complaint?

A. The patient was confused

B. The patient had a respiratory rate of 44

C. The patient stated that she felt sick

D. The patient was found sitting in the driver's seat of the full-size sedan

C. The patient stated that she felt sick

Which of the following is part of the minimum data set developed by the National Highway Traffic Safety Administration​ (NHTSA) for purposes of data collection in conducting​ research?

A. Patient's insurance coverage

B. Amount charged for ambulance services

C. Time of arrival at the patient's location

D. Patient's name

C. Time of arrival at the patient's location

Which of the following should be documented as subjective patient information

A. Description of the surroundings

B. Vital signs

C. Symptoms

D. Medications

C. Symptoms

In which of the following circumstances is a fully documented prehospital care report not necessary?

A. A patient says that someone else called EMS and he does not want any assistance

B. A patient is treated but not transported

C. Multiple patients come from an office building evacuation

D. A fully documented patient care report is required for all of the above

C. Multiple patients come from an office building evacuation

Which of the following agencies assigns and licenses radio frequencies?

A. United States Department of Transportation

B. Federal Trade Commission

C. Federal Communications Commission

D. Transportation Security Administration

C. Federal Communications Commission

Which of the following best describes a portable radio?

A. A​ two-way radio at a fixed site

B. A​ two-way radio that is mounted in a vehicle

C. A device that receives and amplifies signals that must be sent over long distances

D. A​ two-way radio that can be carried on a belt clip

D. A two-way radio that can be carried on a belt clip

You are transporting a city councilman to the hospital after he injured his shoulder playing basketball at his gym. His left shoulder is​ swollen, deformed, and bruised. There is pain and tingling when the patient attempts to use his hand. He has a pulse of 92 per​ minute, a respiratory rate of 20 per​ minute, and a blood pressure of​ 132/88 mmHg. Which of the following should not be included in the radio​ report?

A. The appearance of the shoulder

B. How the injury occurred

C. Notification that extra security is needed for a VIP

D. Vital Signs

C. Notification that extra security is needed for a VIP

Medical direction has requested that you administer 70 grams of activated charcoal to an overdose patient. Which of the following should you do next?

A. Prepare the medication and then call the hospital back to verify the order

B. Document the order in writing before carrying it out

C. Repeat the order back to the physician to make sure you understood correctly

D. Administer the medication without delay

C. Repeat the order back to the physician to make sure you understood correctly

You have received an order from medical direction that you feel would be detrimental to your patient. Which of the following should you do?

A. Carry out the order but document that you disagreed with it

B. Call a different hospital for orders

C. Contact your supervisor for advice

D. Politely question the physician

D. Politely question the physician

Why is it important that your radio report to the receiving facility be concise?

A. The emergency department needs to know quickly and accurately the patient's condition

B. You want to make sure the doctor approves your medical order request.

C. You want to appear professional.

D. You do not want to bore the nurse receiving your report.

A. The emergency department needs to know quickly and accurately the patient's condition

Which of the following is one of the common situations in which an EMT may be liable?

A. Inaccurate recording of times and mileage

B. Failure to document all of a​ patient's medications on the patient care report

C. Failing to get the receiving​ physician's signature on the patient care report

D. Patient refusal of treatment and transport

D. Patient refusal of treatment and transport

What is the best way to communicate with a young pediatric patient?

A. Only talk with the parents. The child is too young to know his or her medical history.

B. Do not tell the child that a procedure will hurt beforehand because the child will become terrified.

C. Sit at the level of the​ child, if​ possible, and always be honest.

D. Tell the child the procedure will hurt much more than it actually will so that he or she will be pleasantly surprised when the procedure is over.

C. Sit at the level of the child, if possible, and always be honest

Which of the following is not part of the medical radio report?

A. Address at which the patient was located

B. Patients response to medical care provided

C. Unit identification

D. Estimated time of arrival

A. Address at which the patient was located

Which of the following is not a reason for routine review of prehospital care reports in a quality improvement program?

A. Assess conformity to patient care standards

B. Satisfy requirements of the shift supervisor

C. Review poor patient care

D. Reveal excellent patient care

B. Satisfy requirements of the shift supervisor

While on the scene with an elderly chest pain​ call, you notice that your partner gets on one knee when talking to the seated patient. What is the best reason for an EMT to kneel down beside the​ patient?

A. The EMT does not want to appear threatening or intimidating to the patient.

B. The EMT can examine the​ patient's chest better.

C. The EMT is kneeling to protect himself.

D. The younger EMT is acknowledging that the older patient is his elder.

A. The EMT does not want to appear threatening or intimidating to the patient

An objective statement made in a prehospital patient care report meets all of the following criteria except which​ one?

A. Observable

B. Verifiable

C. Measurable

D. Biased

D. Biased

Which of the following best describes a mobile radio?

A. A​ two-way radio at a fixed site

B. A​ two-way radio that can be carried on a belt clip

C. A device that receives and amplifies signals that must be sent over a long distance

D. A​ two-way radio that is mounted in a vehicle

D. A two-way radio that is mounted in a vehicle

You are treating a​ 32-year-old man who is deaf. You need to find out why he called for an ambulance. What is the best way to communicate with this​ patient?

A. Call for an interpreter to meet you at the hospital.

B. Speak very loudly in case he has a little hearing.

C. Make sure the patient can see your lips when you speak.

D. Use hand gestures to act out what you are trying to say.

C. Make sure the patient can see your lips when you speak

Your elderly male patient tells you his name is Joe Smith. Which of the following is the best way to address​ him?

A. Smitty

B. Mr. Smith

C. Sir

D. Joe

B. Mr. Smith

Which of the following information on a patient care report is not considered run data?

A. Chief complaint

B. Time of arrival at the receiving facility

C. Time of the incident report

D. Time unit left the scene

A. Chief complaint

You are are responding to a nursing home for an​ 85-year-old patient complaining of difficulty breathing. How would you initiate contact with this​ patient?

A. Stand near the head of the bed and shout to make sure the patient can hear you.

B. Place yourself at eye​ level, identify​ yourself, and ask the patient for her name.

C. Sit on the foot of the bed and ask the patient​ what's up.

D. Pick up the​ patient's wrist and begin taking her pulse.

B. Place yourself at eye level, identify yourself, and ask the patient for her name

You are on a call of a minor vehicle accident. Your patient is a​ 22-year-old male who was the driver of a moderate​ T-bone collision. The patient was not wearing a seat​ belt, and there was spidering of the windshield. The patient complains of neck pain and has a scalp laceration. After performing the primary​ assessment, you take vital signs and bandage the​ patient's scalp. When you tell him you need to backboard​ him, he refuses care and ambulance transport. Because the person is alert and oriented to​ time, place, and​ person, you have the patient sign the separate patient refusal form provided by your service. How should you document this incident in your EMS​ report?

A. You should only document what treatment you performed before the patient refused treatment.

B. You should document your patient care and then simply document that the patient was informed of the risks prior to his refusal. Anything extra is unnecessary and wastes time.

C. You should document everything including all patient​ care, all of your attempts to persuade the patient to go by​ ambulance, and who witnessed the patient refusal.

D. No report is needed because the patient refused transport and signed the refusal.

C. You should document everything including all patient​ care, all of your attempts to persuade the patient to go by​ ambulance, and who witnessed the patient refusal.

Which of the following describes the importance of effective communication of patient information in the verbal​ report?

A. Changes in the​ patient's condition can be communicated.

B. Patient treatment can be based on this information.

C. Additional information that was not given in the radio report can be provided.

D. All of the above

D. All of the above

Which of the following is not an objective element of documented patient information?

A. Patient's complaint of nausea

B. Patient's blood pressure

C. Patient's age

D. Position in which the patient was found

A. Patient's complaint of nausea