EMR: Communication and Documentation

When you document information on a patient that you treat and care for. This written report is called the:

• Patient care report

• Health care report

• Run report

• A and C

You are asked to give testimony in court about the care you gave to a patient. The attorney may ask you about items in your run report because the report (is):

• a legal document

• shows continuity of care

• educational

• provides statistical data

When you write a patient care report, you should be:

• extremely detailed

• quick and sloppy

• objective

• sloppy

When writing patient information down, you could use:

• PDAs or hand-held computers

• laptop computers

• paper forms

• all of the above

You are writing a patient care report. You write 18 for the respiration and it should have been 16. The best way to correct this is to:

• cover the error with white-out.

• Draw a single line through the error.

• erase the error

• none of the above

All are the elements of a patient care report EXCEPT the:

• changes in the patient's condition

• vital signs

• nature of the call

• patient's race

When an Emergency Medical Responder is filling out the required information on a patient care report, this is called the:

• patient care data.

• minimum data set

• maximum data set

• vital signs

All are reasons that an Emergency Medical Responder should have an accurate and well-documented report EXCEPT:

• the report is used for billing information.

• the report documents continuity of care.

• the report provides information to the family.

• the report is a legal document.

You read a patient care report that states that the “patient was attempting to perform a dangerous trick on her skateboard.” What is wrong with writing this in a patient care report?

• The information is not true.

• The information is true

• The information is subjective

• The information is objective

Your engine is called for a car accident. When you get on the scene, you see an unresponsive patient. You call for an ALS ambulance. As they assume patient care, you give them all the information so the ALS ambulance can continue with effective treatments. This is called (the):

• minimum data set

• radio report

• continuity of care

• patient care report