Documentation Special Situations Practice Questions

37 multiple-choice questions on Special situations for paramedic and EMT students, from Chapter 6 (Documentation). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

37 practice questions

1. Documentation of a patient refusal should include:

   1. A. Dispatch details and the time the crew cleared
   2. B. The patient's signature, which covers everything
   3. C. A brief statement that the patient declined care
   4. D. Capacity, risks explained, and patient quotes
   Show answer

   Answer: D. Capacity, risks explained, and patient quotes

   Document capacity assessment, risks explained in plain language, attempts to persuade, the patient's own words, witnesses, and an offer to return. This is the most scrutinized documentation in EMS.

2. If a refusing patient will not sign the refusal form, the paramedic should:

   1. A. Leave, since an unsigned refusal is void anyway
   2. B. Insist on a signature before leaving the scene
   3. C. Document the refusal to sign and get a witness
   4. D. Transport the patient anyway for their safety
   Show answer

   Answer: C. Document the refusal to sign and get a witness

   A witness such as a police officer or family member can sign. A witnessed refusal to sign is itself documentation.

3. At a mass-casualty incident, documentation is typically:

   1. A. Identical to routine calls for every patient
   2. B. Abbreviated on triage tags, completed afterward
   3. C. Not required at all during a declared disaster
   4. D. Completed only by incident command staff
   Show answer

   Answer: B. Abbreviated on triage tags, completed afterward

   Detailed records are completed afterward. Triage tag numbers link patients to records.

4. When restraints are applied, documentation must include:

   1. A. A general statement that restraint was necessary
   2. B. The psychiatric diagnosis that justified restraint
   3. C. Only the medical control physician who approved it
   4. D. Behavior, method, times, and serial reassessment
   Show answer

   Answer: D. Behavior, method, times, and serial reassessment

   Include the behavior requiring restraint, method used, personnel involved, times, and repeated checks of circulation and breathing. Restraint documentation is regularly challenged.

5. Documentation of suspected abuse should contain:

   1. A. The name of the suspected abuser
   2. B. Your conclusion that abuse has taken place
   3. C. A statement accusing the caregiver of harm
   4. D. Injuries, the explanation given, and quotes
   Show answer

   Answer: D. Injuries, the explanation given, and quotes

   Use objective descriptions of injuries, the explanation given, and direct quotes. Investigators reach conclusions; you record observations.

6. When a DNR or POLST form is honored, documentation should include:

   1. A. Nothing further once the form has been honored
   2. B. The names of every family member who was present
   3. C. Document type, who presented it, and its validity
   4. D. Only that the patient died and the time of death
   Show answer

   Answer: C. Document type, who presented it, and its validity

   Also note any medical control contact. Attach or photograph the form per policy.

7. A call cancelled en route should be documented with:

   1. A. A verbal report to the shift supervisor only
   2. B. Nothing, since there was never any patient contact
   3. C. Who cancelled, when, and the unit's disposition
   4. D. The dispatch center's records and nothing more
   Show answer

   Answer: C. Who cancelled, when, and the unit's disposition

   Record the dispatch information, the time and source of the cancellation, and the unit's disposition. Cancellations are sometimes disputed later.

8. If a patient is transferred to another EMS unit, documentation should include:

   1. A. The dispatch time and the unit numbers involved
   2. B. Receiving crew, level, condition, and info shared
   3. C. Nothing beyond the time of the transfer itself
   4. D. Only the name of the eventual destination hospital
   Show answer

   Answer: B. Receiving crew, level, condition, and info shared

   Record the receiving crew, their level of care, condition at transfer, and information exchanged. Care continuity depends on it.

9. After a provider exposure to blood or body fluids, documentation includes:

   1. A. The source patient's name and diagnosis only
   2. B. Nothing, to protect the source patient's privacy
   3. C. A verbal report to the infection control officer
   4. D. Exposure type, PPE worn, time, and actions taken
   Show answer

   Answer: D. Exposure type, PPE worn, time, and actions taken

   Also note any available source information. This documentation supports workers' compensation and follow-up.

10. An incident involving equipment failure should be documented:

    1. A. Both in the chart and in a separate incident report
    2. B. Not at all, as long as the patient was not harmed
    3. C. Verbally to the supervisor at the end of shift
    4. D. Only in the patient care report narrative
    Show answer

    Answer: A. Both in the chart and in a separate incident report

    Document it in the patient care report as it affected care, plus a separate agency incident report. Separate reports keep quality issues out of the patient record.

11. A patient who is transported against their stated wishes under legal authority requires documentation of:

    1. A. The family's request that the patient be taken
    2. B. Only the time of transport and the destination
    3. C. The authority used, who invoked it, and behavior
    4. D. Nothing beyond a standard transport narrative
    Show answer

    Answer: C. The authority used, who invoked it, and behavior

    Document the legal authority, who invoked it, the patient's behavior, and the care provided. Name the officer or the hold document.

12. Multiple patients from one incident should be documented:

    1. A. On the triage tags alone, with no reports
    2. B. On a separate report for each patient
    3. C. On a single combined report for the incident
    4. D. By the incident commander for all patients
    Show answer

    Answer: B. On a separate report for each patient

    Each patient has their own record.

13. Documentation of a patient who refuses assessment entirely should include:

    1. A. Only the refusal and the time that it occurred
    2. B. Nothing, because no assessment was performed
    3. C. A signature, which replaces the need for a narrative
    4. D. What you could observe, statements, and capacity
    Show answer

    Answer: D. What you could observe, statements, and capacity

    Document observations possible from a distance, statements made, capacity indicators, and advice given. You can still observe.

14. Documenting a refusal where the patient appeared intoxicated:

    1. A. Is routine as long as the refusal form is signed
    2. B. Requires careful capacity assessment and detail
    3. C. Is impossible, since intoxicated refusals are void
    4. D. Should be avoided by leaving before a refusal
    Show answer

    Answer: B. Requires careful capacity assessment and detail

    It requires a careful capacity assessment and detailed description of behavior and understanding. These are high-risk.

15. Documenting an against-medical-advice refusal should note:

    1. A. A general warning that refusing may be harmful
    2. B. Only the time and the witness's name
    3. C. Only the patient's signature on the AMA form
    4. D. That the patient understood specific named risks
    Show answer

    Answer: D. That the patient understood specific named risks

    Note that the patient was advised, understood, and chose to refuse, with specific risks named. Specific risks, not general warnings.

16. Documentation of a patient who leaves before assessment:

    1. A. Is left to the police officers on the scene
    2. B. Is limited to one line noting that they left
    3. C. Should describe attempts to assess and departure
    4. D. Is unnecessary, since no patient contact occurred
    Show answer

    Answer: C. Should describe attempts to assess and departure

    Describe the attempts to assess and the circumstances of departure, such as: patient walked away despite requests to remain.

17. Documentation of a minor treated without a parent present should include:

    1. A. Nothing special if the minor agreed to care
    2. B. The consent basis and attempts to reach a parent
    3. C. Only the patient's age, verified by an ID card
    4. D. Only the treatment given and the patient's response
    Show answer

    Answer: B. The consent basis and attempts to reach a parent

    State the consent basis, such as emergency or in loco parentis, and notification attempts. Consent basis must be clear.

18. Documentation of an emancipated minor should include:

    1. A. The parent's name and the time they were called
    2. B. Nothing, since they are treated as adults anyway
    3. C. The basis for emancipation the patient stated
    4. D. Only the patient's age, as shown on a photo ID
    Show answer

    Answer: C. The basis for emancipation the patient stated

    Note what they told you about why they are emancipated.

19. At a 15-patient bus crash, you are assigned to treatment. How should you document care during the incident?

    1. A. Complete a full ePCR for each patient before you move to the next one
    2. B. Document nothing at all until the entire incident has ended
    3. C. Write one combined report that covers all of the patients at once
    4. D. Record findings and care on each triage tag; write full reports afterward
    Show answer

    Answer: D. Record findings and care on each triage tag; write full reports afterward

    In an MCI, documentation is shortened so it doesn't slow care. Triage tags travel with the patient and record the priority, key findings, and treatments. Full individual reports are written afterward, using the tag numbers to link records. Writing a full report for each patient during the incident delays care for others. Recording nothing loses information. Each patient still needs a separate record.

20. Documentation of a patient transported by another unit after your assessment should:

    1. A. Be skipped, since the other unit writes the report
    2. B. Be combined into the transporting unit's report
    3. C. Include your assessment, care, and the transfer
    4. D. Be given verbally to the transporting crew only
    Show answer

    Answer: C. Include your assessment, care, and the transfer

    Each provider documents their contact.

21. Documentation of a cancelled call after patient contact should:

    1. A. Describe the contact, findings, and who cancelled
    2. B. Be given verbally to dispatch and not charted
    3. C. Be skipped, since the call was ultimately cancelled
    4. D. Be limited to the time of the cancellation only
    Show answer

    Answer: A. Describe the contact, findings, and who cancelled

    Contact creates a record.

22. Documentation of a patient found deceased without resuscitation should include:

    1. A. Only the time the crew first found the patient
    2. B. Only the notification made to law enforcement
    3. C. Nothing, since no care was provided to the patient
    4. D. Presumptive signs, findings, and notifications
    Show answer

    Answer: D. Presumptive signs, findings, and notifications

    Include the assessment findings supporting the decision, presumptive signs of death, and notifications. The reasoning must be clear.

23. Documentation of a resuscitation should include:

    1. A. Only the presenting rhythm and the final rhythm
    2. B. Times, interventions, rhythms, and response
    3. C. Only the medications given and the total doses
    4. D. Only the final outcome and the time of transfer
    Show answer

    Answer: B. Times, interventions, rhythms, and response

    Include times of arrest, interventions, rhythms, medications, and response. A timeline is essential.

24. Documentation of termination of resuscitation should include:

    1. A. Criteria met, physician order, and the time
    2. B. Only the time that resuscitation was stopped
    3. C. Nothing beyond the original cardiac arrest report
    4. D. Only the physician's name, without criteria
    Show answer

    Answer: A. Criteria met, physician order, and the time

    Include criteria met, medical control contact, the physician's name, and time of termination. These cases are reviewed.

25. Documentation of an on-scene physician's involvement should include:

    1. A. Nothing, since physicians document separately
    2. B. Identity, verification, orders, and who has care
    3. C. Only the physician's name and medical specialty
    4. D. Only the orders, without verifying identity
    Show answer

    Answer: B. Identity, verification, orders, and who has care

    Document identity, verification, orders given, and whether they assumed care. Follow protocol.

26. Documentation of a psychiatric patient should include:

    1. A. A psychiatric diagnosis such as schizophrenia
    2. B. Only the behavior, without quoting the patient
    3. C. Only the hold paperwork and the officer's name
    4. D. Behavior, statements, risk, and legal basis
    Show answer

    Answer: D. Behavior, statements, risk, and legal basis

    Include observed behavior, statements, risk indicators, and the legal basis for transport if involuntary. Describe, do not diagnose.

27. Documentation of a sexual assault patient should:

    1. A. Record injuries and essential history only
    2. B. Include a detailed, step-by-step assault history
    3. C. Include your view on whether the account is true
    4. D. Be minimal, leaving out injuries for privacy
    Show answer

    Answer: A. Record injuries and essential history only

    Avoid unnecessary questioning and note evidence preservation. Specialized examiners take the detailed history.

28. Documentation of a suspected overdose should include:

    1. A. Nothing about drugs, to protect the patient
    2. B. Only the naloxone dose, route, and time given
    3. C. Only the patient's response to treatment
    4. D. Suspected substances, evidence, care, and response
    Show answer

    Answer: D. Suspected substances, evidence, care, and response

    Describe pill bottles and paraphernalia objectively.

29. Documentation of a patient with a language barrier should include:

    1. A. Language, interpreter, and gaps in history
    2. B. Only the primary language the patient speaks
    3. C. Nothing, if family members helped translate
    4. D. Only the name of the interpreter who helped
    Show answer

    Answer: A. Language, interpreter, and gaps in history

    Include the language, the interpreter used, and any limitations in the history. Explain gaps.

30. Documentation of an interfacility transfer should include:

    1. A. Only the names of the two facilities involved
    2. B. Only the receiving facility and bed assignment
    3. C. Reason, physicians, care en route, and changes
    4. D. Only the departure and arrival times of the trip
    Show answer

    Answer: C. Reason, physicians, care en route, and changes

    Include the reason for transfer, sending and receiving physicians, care en route, and condition changes. Records should accompany the patient.

31. You withhold CPR for a patient in arrest after her daughter shows you a state out-of-hospital DNR. Which entry best documents this?

    1. A. "DNR present per the family, so no CPR was started on scene."
    2. B. "State OOH-DNR dated 3/2/26, shown by daughter, verified; no CPR."
    3. C. "Family members on scene did not want any CPR performed."
    4. D. "Pt was old and terminally ill, so no CPR was started."
    Show answer

    Answer: B. "State OOH-DNR dated 3/2/26, shown by daughter, verified; no CPR."

    Document the type of form, the key details that make it valid, who presented it, how you verified it, and the resulting decision. This shows the decision was based on a legal order and not a family wish or an assumption. A DNR described only by family, with no form type or verification, gives no proof of validity. A family's wishes alone and the patient's age or illness are not legal grounds to withhold resuscitation.

32. Documentation of a hazmat exposure should include:

    1. A. Only the symptoms the patient reported on scene
    2. B. Substance, route, decon done, and symptoms
    3. C. Only the decontamination steps that were done
    4. D. Only the substance named by the fire service
    Show answer

    Answer: B. Substance, route, decon done, and symptoms

    Include the substance, exposure route, decontamination performed, and symptoms. It supports treatment and provider follow-up.

33. Documentation of patient restraint should note reassessment of:

    1. A. Behavior only, to decide when to remove them
    2. B. Circulation, breathing, and mental status
    3. C. Nothing once the restraints are confirmed secure
    4. D. Distal circulation in the restrained limbs only
    Show answer

    Answer: B. Circulation, breathing, and mental status

    Reassess at regular intervals. Deaths have occurred in restraint.

34. Documentation of a patient's weapon found during care should:

    1. A. Be omitted to avoid involvement in the case
    2. B. Name the weapon type, without further detail
    3. C. Describe it, where it was, and who took it
    4. D. Be reported verbally to police, not charted
    Show answer

    Answer: C. Describe it, where it was, and who took it

    Describe what was found, where, and to whom it was given. Chain of custody matters.

35. Documentation of a bariatric patient should include:

    1. A. Resources, equipment, staff, and delays
    2. B. Only the patient's estimated body weight
    3. C. Only the special equipment that was used
    4. D. Nothing special beyond a standard report
    Show answer

    Answer: A. Resources, equipment, staff, and delays

    Document resources used, equipment, personnel, and any delays related to movement. It explains scene time.

36. Documentation of a pregnant patient should include:

    1. A. Gestational age, complications, fetal status
    2. B. Nothing beyond a standard medical assessment
    3. C. Only the gestational age the patient reports
    4. D. Only maternal vital signs, as for any patient
    Show answer

    Answer: A. Gestational age, complications, fetal status

    Fetal status is documented when assessable. Two patients.

37. Documentation of a newborn delivered in the field should include:

    1. A. Only the interventions given to the newborn
    2. B. Birth time, APGAR scores, and care given
    3. C. Only the APGAR scores at one and five minutes
    4. D. Only the time of birth on the mother's report
    Show answer

    Answer: B. Birth time, APGAR scores, and care given

    Include time of birth, APGAR scores, interventions, and both patients' condition. Usually a separate report for the newborn.