42) Which of the following is NOT appropriate to document on your patient care report?
A) Patient’s attitude
B) Patient’s mental status
C) Patient’s race
D) All should be documented
Objective: 15.11
43) Which of the following should be documented as subjective patient information?
A) Medications
B) Signs
C) Description of the surroundings
D) Symptoms
Objective: 15.11
44) Which of the following is NOT an objective element of documented patient information?
A) Position in which the patient was found
B) Patient’s complaint of nausea
C) Patient’s blood pressure
D) Patient’s age
Objective: 15.11
21
45) 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 had wheezes that were audible without using a stethoscope.
C) The patient has a history of asthma.
D) The patient was having an asthma attack.
Objective: 15.11
46) Patient data includes all of the following except the:
A) nature of the dispatch.
B) patient’s medications.
C) patient’s chief complaint.
D) mechanism of injury.
Objective: 15.11
22
47) 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 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 only the actual exam findings. Do not document anything that was said.
D) Document any pertinent information that was said by the stepmother and child exactly in
quotations.
Objective: 15.11
23
48) 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) No report is needed because the patient refused transport and signed the refusal.
B) You should only document what treatment you performed before the patient refused
treatment.
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) 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.
Objective: 15.11
24
49) Two EMTs are on-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 was violent and bit the EMT
B) The fact that the EMT had an exposure incident
C) The fact that the patient hears voices
D) The fact that the patient slashed his wrists
Objective: 15.11
50) 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) Patient’s name
D) Time of arrival at the patient’s location
Objective: 15.12
25
51) Which of the following is the correct manner for making a correction on a patient care
report?
A) Get a credible witness to co-sign your patient care report.
B) Draw a single line through the error and initial it.
C) Use typing correction fluid to cover up the error and write over it.
D) Blacken out the entire error and draw an arrow to the correct information.
Objective: 15.12
52) Which of the following does NOT need to be documented regarding a patient refusal of
treatment?
A) That you informed the patient of the consequences of refusing care
B) Patient’s mental status
C) Any insulting remarks the patient made to you
D) That you advised the patient to call back if he changed his mind
Objective: 15.12
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