Documentation in Paramedic Operations Review Questions with complete Solutions Rated A+
What is the legal record for the call and part of your patients medical record. Pg 170 - Answers Patient
care report
What information includes measurable signs that you observe and and record. Pg 170 - Answers
Objective information
What type of information includes information that is told to you but cannot be seen. Pg 170 - Answers
Subjective information.
What stores and standardizes EMS data from each individual state. Pg 172 - Answers The National
Emergency Medical Services Information System. (NEMSIS)
What kind of data consists of the incident times, locations, responding units, and names of crew. Pg 173
- Answers Run data
What kind of data includes chief complaint, vital signs, assessment, etc. pg 173 - Answers Patient Data
When a patient refuses care, what should you ensure that your patient knows. pg 174 - Answers Their
current situation and their right to refuse care.
What is essential to have during the refusal process to ensure your patient has knowledge of their
situation. pg 175 - Answers A witness
According to ________, workplace injuries must be logged. pg 175 - Answers OSHA
What PCR style explains a call in a story format from the time it started to the time it finished. pg 179 -
Answers Chronological order
What PCR style is a simple and logical method that allows you to document various aspects of the
patient care encounter. pg 179 - Answers SOAP (Subjective, Objective, Assessment, Plan)
What PCR style is similar to SOAP but allows you to break down the narrative into logical sections. pg
179 - Answers CHARTE (Chief complaint, History, Assessment, Treatment, Transport, Exceptions)
What is a record of negative findings that warrant no care or intervention but indicate that a thorough
exam and history were performed pg 181 - Answers Pertinent Negatives
What is a written report that is left behind with the patient. pg 182 - Answers Drop/transfer report
What can you use if you forget important information on a PCR. pg 185 - Answers Addendum
What can pose huge legal implications for a paramedic. pg 185 - Answers Lost reports
What is the legal record for the call and part of your patients medical record. Pg 170 - Answers Patient
care report
What information includes measurable signs that you observe and and record. Pg 170 - Answers
Objective information
What type of information includes information that is told to you but cannot be seen. Pg 170 - Answers
Subjective information.
What stores and standardizes EMS data from each individual state. Pg 172 - Answers The National
Emergency Medical Services Information System. (NEMSIS)
What kind of data consists of the incident times, locations, responding units, and names of crew. Pg 173
- Answers Run data
What kind of data includes chief complaint, vital signs, assessment, etc. pg 173 - Answers Patient Data
When a patient refuses care, what should you ensure that your patient knows. pg 174 - Answers Their
current situation and their right to refuse care.
What is essential to have during the refusal process to ensure your patient has knowledge of their
situation. pg 175 - Answers A witness
According to ________, workplace injuries must be logged. pg 175 - Answers OSHA
What PCR style explains a call in a story format from the time it started to the time it finished. pg 179 -
Answers Chronological order
What PCR style is a simple and logical method that allows you to document various aspects of the
patient care encounter. pg 179 - Answers SOAP (Subjective, Objective, Assessment, Plan)
What PCR style is similar to SOAP but allows you to break down the narrative into logical sections. pg
179 - Answers CHARTE (Chief complaint, History, Assessment, Treatment, Transport, Exceptions)
What is a record of negative findings that warrant no care or intervention but indicate that a thorough
exam and history were performed pg 181 - Answers Pertinent Negatives
What is a written report that is left behind with the patient. pg 182 - Answers Drop/transfer report
What can you use if you forget important information on a PCR. pg 185 - Answers Addendum
What can pose huge legal implications for a paramedic. pg 185 - Answers Lost reports
