EMT-Basic Patient Assessment
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Questions and Answers

Which of the following is NOT a component of the minimum data set to be gathered by EMT-Basics?

  • Respiratory rate and effort
  • Skin color and temperature
  • Patient's medical history (correct)
  • Systolic blood pressure for patients older than 3 years

    • Patient confidentiality applies to the PCR (Prehospital Care Report) form and all information documented on it.

    True

    What should an EMT-Basic do if a competent adult patient refuses treatment?

    Document the assessment findings and emergency medical care given, then have the patient sign a refusal form.

    For patients under 3 years old, the EMT-Basic should assess _____ for skin perfusion.

    <p>capillary refill</p> Signup and view all the answers

    Match the term with its correct description:

    <p>Confidentiality = Protection of patient information Distribution = Where PCR forms are sent Documentation = Recording of patient care provided Refusal of treatment = Patient's right to decline medical care</p> Signup and view all the answers

    What is the primary purpose of accurate and synchronous clocks in patient care documentation?

    <p>To accurately record the timeline of patient care</p> Signup and view all the answers

    EMT-Basics can document a patient's refusal of treatment without any witnesses.

    <p>False</p> Signup and view all the answers

    List two components that must be recorded during reassessment of a patient.

    <p>Time and findings</p> Signup and view all the answers

    What is one of the primary legal functions of a Prehospital Care Report (PCR)?

    <p>To serve as a legal document with detailed patient information</p> Signup and view all the answers

    A Prehospital Care Report should include both objective and subjective information.

    <p>True</p> Signup and view all the answers

    Why is accurate documentation important in emergency medical situations?

    <p>It ensures continuity of care, provides legal protection, and supports patient assessment and treatment.</p> Signup and view all the answers

    A good Prehospital Care Report provides information that includes patient demographics, treatment administered, and __________ vital signs.

    <p>baseline</p> Signup and view all the answers

    Which of the following is NOT a reason for documentation in medical settings?

    <p>Marketing services</p> Signup and view all the answers

    Match the following types of information with their appropriate PCR sections:

    <p>Run data = Administrative information Patient name = Demographic data Vital signs = Check boxes Narrative observations = Narrative section</p> Signup and view all the answers

    It is acceptable to use radio codes in the narrative section of a PCR.

    <p>False</p> Signup and view all the answers

    What should be included when documenting information of a sensitive nature?

    <p>The source of the information should be noted.</p> Signup and view all the answers

    What should an EMT-Basic do if an error occurs during documentation?

    <p>Document the error and the steps taken to correct it</p> Signup and view all the answers

    Falsifying information on a prehospital care report can lead to suspension of an EMT-Basic's certification.

    <p>True</p> Signup and view all the answers

    What must an EMT-Basic document if they fail to provide a specific treatment to a patient?

    <p>The EMT-Basic must document that the treatment was not given.</p> Signup and view all the answers

    An EMT-Basic should inform the patient of the potential __________ of refusing care.

    <p>consequences</p> Signup and view all the answers

    Match the following documentation practices with their correct description:

    <p>Documenting vital signs = Only record actual vital signs taken Covering up errors = Not an acceptable practice Correcting errors in submitted reports = Draw a line through the error and add the correct information Explaining care refusal = Explain consequences, including potential death</p> Signup and view all the answers

    What should be done if important information is omitted from a report after submission?

    <p>Add a note with the correct information and the EMT-Basic's initials</p> Signup and view all the answers

    An EMT-Basic is allowed to document vital signs that were not actually taken as long as it seems plausible.

    <p>False</p> Signup and view all the answers

    What should an EMT-Basic use to record important medical information temporarily during a multiple-casualty incident?

    <p>A triage tag or similar temporary record</p> Signup and view all the answers

    Study Notes

    Documentation Guidelines

    • Ensure correct spelling, particularly for medical terminology; seek alternatives if unsure.
    • Record time and findings for every reassessment, adhering to state or local requirements.

    Minimum Data Set

    • Patient information must be collected upon initial contact:
      • Chief complaint
      • Level of consciousness (AVPU)
      • Systolic blood pressure (patients >3 years)
      • Skin perfusion (capillary refill for patients <3 years)
      • Skin color and temperature
      • Pulse rate
      • Respiratory rate and effort

    Administrative Information

    • Document critical times:
      • Incident reported
      • Unit notified
      • Arrival at patient
      • Departure from scene
      • Arrival at destination
      • Transfer of care
    • Confidentiality is crucial; PCR forms and their data must remain private.
    • Distribution of documentation is dictated by local and state protocols.
    • Competent adults can refuse treatment; if so:
      • Attempt to persuade the patient to seek help.
      • Ensure the patient is making an informed decision free of impairment.
      • Explain potential consequences of refusal.
      • Document assessment findings and care provided.
      • Secure signatures as necessary.

    Prehospital Care Report (PCR)

    • Serves multiple purposes:
      • Ensures continuity of care and serves as a legal document.
      • Captures objective and subjective patient information.
      • Used for educational and research purposes, and to evaluate quality.

    Use of PCR

    • Formats include traditional written forms and computerized versions.
    • Components of the PCR:
      • Administrative details (date, times, service, crew names).
      • Demographic data (patient's name, address, insurance, mechanism of injury).
      • Vital signs should be correctly recorded in check boxes.
      • Narrative section should include detailed observations without conclusions.

    Falsification Issues

    • Errors must be reported truthfully; do not attempt to cover them up.
    • Document only the vital signs taken and treatments administered.
    • Correction procedures include clear reporting of errors using a single line through mistakes, with initials and corrected information noted.

    Special Situations

    • In Multiple-Casualty Incidents (MCI), complete reports may be delayed; temporarily record vital information (e.g., using triage tags).
    • Transfer-of-care reports may have specific requirements depending on local protocols.

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    Description

    This quiz focuses on the essential elements of patient assessment for EMT-Basic training. It covers proper documentation practices, including the importance of recording findings and patient information during initial contact and reassessments. Test your knowledge on medical terminology and data collection protocols in emergency medicine.

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