10 free EMT practice questions: Documentation (PCR)

A note in the crew's shift log rather than a report: A note in the shift log fits things like a call where no patient was found, or an equipment problem. You assessed a hand injury. An actual patient contact needs a full patient care report, not a log entry.

A report only if the employer later requests one: A report only on request would work if something were already on file waiting to be pulled. Here nothing gets written down until the employer asks. The requirement starts at the moment of the patient contact. Nobody has to ask for it.

No report, because the patient was not transported: Skipping the report because there was no transport treats the ambulance ride as the only thing you document. You still assessed a hand injury and handed care to the nurse. A report covers every patient contact, with or without transport. The hand-off to the nurse is part of what the report has to show.

The lot number printed on the auto-injector device: A lot number matters when a device gets recalled or a bad reaction has to be traced back to one batch. Lot numbers go on the stocking and inventory logs. The lot number is not part of charting how this child responded to this dose.

A bystander's opinion of what caused the reaction: A bystander may really believe the sting caused the hives and the trouble breathing. History like that has a place in the narrative. The bystander's opinion is still a guess, not something you assessed. The opinion tells you nothing about how this child responded to the epinephrine.

The name of the physician who signed the protocol: Every EMS system works under protocols signed by a physician. The physician's name belongs in the agency's standing order paperwork. Leaving the name off this report does not make the medication entry incomplete.

The time the stretcher was returned to the ambulance: The time the stretcher went back to the ambulance shows when the unit was getting back in service. The stretcher time never names who took the patient.

The number of the treatment room the patient entered: A treatment room number is hospital tracking. The room number shows where the patient ended up, not who accepted responsibility for the patient.

The name of the physician assigned to the department: The physician assigned to the department is a real person in the emergency department. Being assigned to the department does not mean that physician personally took this patient. The report needs the person who actually assumed care.

Provide a brief update on the patient's injuries and current status at the hospital: A work injury gives the employer a real interest, so a quick update sounds reasonable. The supervisor is not part of the care team and does not have the patient's consent. The injuries and current condition are exactly the information confidentiality protects.

Confirm the patient's name and that he or she arrived safely, but no further details: Giving only the name and safe arrival sounds safer than a full update, since less information is shared. Confirming that a specific patient was treated and transported is itself protected health information. Without the patient's consent, even that small amount cannot be shared.

Refuse to take the call and end the conversation immediately: Refusing the call and hanging up does protect the patient's information. The question asks for the appropriate response, though. Hanging up leaves a supervisor who is worried about an injured worker with nowhere to go. Sending the supervisor to the hospital's release process protects the same information and still helps.

Do not provide any care to a patient refusing transport; document the refusal and leave the scene: Giving no care is right only when a patient has refused everything, because treating a competent adult against their wishes is battery. This patient agreed to oxygen, vital signs, and a focused assessment. Holding back care the patient asked for is abandonment, not caution. Giving no care also leaves you with no documented findings to back up what you did or did not do.

Provide only oxygen without obtaining vital signs or assessment, then leave the scene: Giving only oxygen and skipping the vital signs and the assessment is the bare minimum before leaving. The patient agreed to the assessment and the vital signs, so there is no reason to skip them. A chest pain patient who refuses transport is the kind of call most likely to have the report reviewed later. Without vital signs, nothing shows what the patient's condition was when the patient made the decision.

Advise the patient that accepting some care obligates him to transport; refuse to provide partial care: Telling the patient that accepting oxygen means they have to be transported is coercion, and the claim is false. Consent to one intervention never binds a patient to another. Misleading the patient also ruins the informed part of informed refusal. The approach backfires too. A patient told that accepting anything means accepting everything will refuse everything, and a sick patient ends up with no oxygen and no assessment.

Revise the original narrative so the filed report reads correctly: Revising the narrative would make the filed report read correctly. Changing the original entry of a submitted legal document wipes out the record of what was first filed. Most electronic systems are built to block that kind of change. They allow date-stamped amendments but no erasing in a completed report.

Print the report, line through the incomplete section, and initial it: A single line through the error with your initials is how you fix a mistake while you are still writing a paper report. This report has already been submitted. A line through a section also adds nothing, because the oral glucose was never entered in the first place. Marking up a printout is only a fallback when the electronic system cannot accept a change, and this system allows amendments.

Note the omission in the quality improvement file and leave the report as filed: Noting the omission for quality improvement tells the agency about the mistake. The patient's medical record would still show no oral glucose given. Anyone reading the chart later would be misled. Information left out of a report gets added to the report, not written down somewhere else.

Have both crew members sign the form in place of the patient: The witness signature has to come from someone outside the crew. If the refusal is questioned later, the crew's own care is what gets questioned. Two crew signatures add nothing the narrative does not already say.

Contact medical direction for authorization to transport the patient: Medical direction cannot authorize transporting a patient with capacity who has refused. Refusing to sign is not a sign of poor judgment. This patient is alert and oriented, has no alcohol odor or head injury, has normal vital signs, and can repeat back the risks. Those findings show decision-making capacity.

Leave the signature area blank and note the refusal in the narrative: Writing the refusal in the narrative is part of the documentation, and the signature area still needs a witness. The standard is to have a family member, a police officer, or a bystander sign that the patient declined to sign. Leaving the signature area blank gives up the strongest documentation you have. Two possible witnesses are standing on this scene.

The time of arrival at the emergency department and the hallway location: Arrival time is its own required part of the report. Nobody accepted the patient at 1412. You were still responsible for the patient in that hallway. A report that shows only the arrival time leaves seventeen minutes of care unaccounted for.

The time the room was assigned and the room number: The room number goes in the report as part of the receiving facility information. Assigning a room is a bookkeeping step by the department. No clinician accepted the patient at 1420, so responsibility did not move.

The time the written report was completed and left at the nurses' station: Leaving a written report at the nurses' station does not tell anyone they now have the patient. A report left on a desk names nobody who accepted care.

Abandonment: when a provider leaves a patient without handing care off to someone with equal or higher training. Nothing here says the provider left the patient. This lawsuit is about the care the provider gave.

Assault: putting a person in fear of immediate harm. Assault has nothing to do with whether the care met the standard of care. A lawsuit over a patient's death turns on the standard of care.

Malpractice: a professional doing something they should not have done. Negligence is failing to do something you should have done. Either way, what the family has to prove in court is negligence: duty, breach, causation, and harm.

Access the original report and edit it directly to include the detail: Editing the original report changes the record after the fact, and nothing shows that a change was made. The report is a legal document, and a hidden change makes it unreliable.

Verbally inform the receiving facility instead of updating the record: Telling the receiving facility out loud does not fix the written report. The detail you left out still has to be documented in the record itself.

Leave the original report as submitted, since it cannot be changed: Leaving the report alone treats it as something that can never be changed. A submitted report can be corrected. The correction has to go in an addendum instead of an edit to the original.