EMR: Chapter 8 Quiz Principles of Effective Documentation

An Emergency Medical Responder makes sure the receiving health-care professional is properly informed of the patient’s progression and care. This insures:

continuity of care

Which of the following is NOT part of the minimum data set that an Emergency Medical Responder should give when transferring care?

chief complaint

You are on a call with a patient who appears to be intoxicated. He is yelling profanity at you and your partner. He admits to drinking a fifth of whiskey over the day. Which of the following would be appropriate to document in your report? 

the patient states he has had a “fifth of whiskey to drink”

Your patient care report may be called into a civil or criminal court due to the fact that:

it is considered a legal document

It is important to document thoroughly and accurately because:

if an action of intervention is not documented, it may be concluded that we did not actually perform an action or intervention

The ________ is the part of the patient care report (PCR) in which the Emergency Medical Responder documents that the patient has been turned over to an ambulance.

disposition

The part of the patient care report that includes the patient’s name, address, date of birth, and sex is the:

patient data section

Which of the following is TRUE regarding narrative writing?

it should contain objective information

All of the following regarding correcting errors is true EXCEPT:

white-out should be used

Which of the following is NOT considered a form of electronic documentation?

writing on paper with lighted pen