Elements of a Complete Patient Care Report Practice Questions

37 multiple-choice questions on Elements of a complete report 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. Administrative information on a patient care report includes:

   1. A. Medications given, doses, and patient response
   2. B. Vital signs, exam findings, and impression
   3. C. Unit, crew, call times, location, and demographics
   4. D. The narrative describing the scene and care
   Show answer

   Answer: C. Unit, crew, call times, location, and demographics

   Unit, crew, times, incident location, and patient demographics are administrative data. Times and crew identification matter in legal review.

2. Which times should be recorded for a typical call?

   1. A. Only the start and end times of the transport leg
   2. B. Only the time of first contact with the patient
   3. C. Each benchmark from dispatch to back in service
   4. D. Only the arrival and departure times at the scene
   Show answer

   Answer: C. Each benchmark from dispatch to back in service

   Record dispatch, en route, on scene, at patient, leaving scene, at destination, and back in service. These times document the timeline of care.

3. The chief complaint should be documented:

   1. A. In medical terms, translated from the patient
   2. B. As your field impression after the assessment
   3. C. As the reason given by dispatch on the call
   4. D. In the patient's own words when possible
   Show answer

   Answer: D. In the patient's own words when possible

   Quotation marks show it came from the patient.

4. Vital signs should be recorded:

   1. A. Only on patients who are being transported
   2. B. At least twice, more often if unstable
   3. C. Once, at the time of first patient contact
   4. D. Only when the first set is outside normal
   Show answer

   Answer: B. At least twice, more often if unstable

   Most patients need at least two sets, with more frequent sets for unstable patients. A single set shows no trend, which is what clinicians need.

5. Pertinent negatives are:

   1. A. Expected findings that were absent
   2. B. Negative remarks about patient behavior
   3. C. Findings the provider did not assess
   4. D. Complications that developed during care
   Show answer

   Answer: A. Expected findings that were absent

   Pertinent negatives are expected findings that were absent, which help narrow the problem. "No chest pain, no shortness of breath" is clinically meaningful.

6. Documentation of treatment should include:

   1. A. The name of the intervention and nothing more
   2. B. Intervention, time, dose, provider, response
   3. C. Medications given, but not the procedures done
   4. D. Only interventions that succeeded, with times
   Show answer

   Answer: B. Intervention, time, dose, provider, response

   Include the intervention, time, dose or setting, who performed it, and the patient's response. Response to treatment is often the most useful part.

7. An unsuccessful procedure, such as a failed IV attempt, should be:

   1. A. Omitted, since no fluid or drug was given
   2. B. Recorded only if the attempt caused harm
   3. C. Reported verbally at hand-off, not charted
   4. D. Documented with attempts and next steps
   Show answer

   Answer: D. Documented with attempts and next steps

   Document the number of attempts and what was done next. Omission looks like concealment if questioned later.

8. The patient's mental status should be documented:

   1. A. With a single summary word such as 'normal'
   2. B. Only for trauma patients with a head injury
   3. C. Only when it is found abnormal at first contact
   4. D. On arrival and at reassessment, in detail
   Show answer

   Answer: D. On arrival and at reassessment, in detail

   Document it on arrival and again during reassessment, with specific descriptions. "Alert and oriented to person, place, time, and event" beats "A&Ox4" alone in a disputed case.

9. Signatures that may be required on a report include:

   1. A. A family member's signature on every report
   2. B. The attending paramedic's signature and no other
   3. C. The medical director's signature on each report
   4. D. Receiving provider, and patient when required
   Show answer

   Answer: D. Receiving provider, and patient when required

   The receiving provider signs, and the patient or representative signs when consent, refusal, or billing authorization applies. Requirements vary by state and agency.

10. Documentation of the receiving facility and person assuming care establishes:

    1. A. That care was handed off, not abandoned
    2. B. The patient's chief complaint at arrival
    3. C. That the call qualifies for billing as ALS
    4. D. That the unit met its response time standard
    Show answer

    Answer: A. That care was handed off, not abandoned

    Recording who assumed care shows care was properly transferred, which protects against abandonment claims. Record the name and title when you can.

11. Recording the mechanism of injury or nature of illness helps the receiving team by:

    1. A. Describing forces that predict injury patterns
    2. B. Allowing triage without a full physical exam
    3. C. Setting the billing level for the transport
    4. D. Documenting that the scene was safe for the crew
    Show answer

    Answer: A. Describing forces that predict injury patterns

    The forces or circumstances involved predict injury patterns. Details such as deformity, speed, and restraint use matter.

12. Equipment left with the patient, such as a cervical collar or IV, should be:

    1. A. Assumed to be noticed by the hospital staff
    2. B. Noted only if the device is unusual or rare
    3. C. Removed before the patient is transferred
    4. D. Documented and communicated at hand-off
    Show answer

    Answer: D. Documented and communicated at hand-off

    It also helps the agency recover equipment.

13. Patient demographics include:

    1. A. Name, age, sex, date of birth, and address
    2. B. Medications, allergies, and last oral intake
    3. C. Vital signs, weight, height, and allergies
    4. D. Chief complaint and past medical history
    Show answer

    Answer: A. Name, age, sex, date of birth, and address

    Identification is essential.

14. The incident location should be documented:

    1. A. By city and county only, for data reporting
    2. B. Approximately, by nearest cross street
    3. C. Precisely, including address and unit number
    4. D. Only when the scene was unusual or unsafe
    Show answer

    Answer: C. Precisely, including address and unit number

    Record the address, apartment, and a scene description. It may matter later.

15. Documenting the type of location, such as home, work, or roadway:

    1. A. Is collected only for later law enforcement use
    2. B. Gives context and is a standard data element
    3. C. Is optional and left to provider preference
    4. D. Is unnecessary once the street address is recorded
    Show answer

    Answer: B. Gives context and is a standard data element

    NEMSIS captures it.

16. Dispatch information documented should include:

    1. A. Only the address that dispatch provided
    2. B. Only the time the call was first received
    3. C. The dispatched complaint and priority
    4. D. Nothing, since dispatch keeps its own log
    Show answer

    Answer: C. The dispatched complaint and priority

    The dispatched complaint and priority may differ from your findings. Differences explain response decisions.

17. The initial general impression should be documented because:

    1. A. Agency policy requires it on every chart
    2. B. It replaces the need for a primary survey
    3. C. It records the first judgment of acuity
    4. D. Billing uses it to set the level of service
    Show answer

    Answer: C. It records the first judgment of acuity

    Sick or not sick: it captures the first clinical judgment of acuity.

18. Level of consciousness documentation should describe:

    1. A. Orientation to person, place, and time only
    2. B. A single word such as 'confused' or 'drowsy'
    3. C. Only whether the patient is alert or not alert
    4. D. The stimulus and response, as in AVPU or GCS
    Show answer

    Answer: D. The stimulus and response, as in AVPU or GCS

    Describe the specific stimulus and response, such as AVPU or GCS components. Precise descriptions allow comparison.

19. Airway status documentation includes:

    1. A. Only details of any advanced airway placed
    2. B. Patency, interventions, and any obstruction
    3. C. Only 'patent' if no airway device is used
    4. D. Nothing at all when the airway is normal
    Show answer

    Answer: B. Patency, interventions, and any obstruction

    Include patency, interventions, and any obstruction or risk. Normal findings are documented too.

20. Breathing documentation should include:

    1. A. Only the breath sounds heard in each lung field
    2. B. Only the pulse oximetry reading on room air
    3. C. Only the respiratory rate counted on scene
    4. D. Rate, depth, effort, lung sounds, and SpO2
    Show answer

    Answer: D. Rate, depth, effort, lung sounds, and SpO2

    Document rate, depth, effort, breath sounds, and oxygen saturation. Each element matters.

21. Circulation documentation should include:

    1. A. Only the blood pressure by auscultation
    2. B. Only the pulse rate taken at the radial site
    3. C. Pulse, skin signs, refill, and any bleeding
    4. D. Only skin color, temperature, and moisture
    Show answer

    Answer: C. Pulse, skin signs, refill, and any bleeding

    Include pulse rate and quality, skin signs, capillary refill, and bleeding. Perfusion is a composite.

22. The physical exam documentation should:

    1. A. Fit on one line listing the regions checked
    2. B. Record relevant normal and abnormal findings
    3. C. Note only the abnormal findings to save space
    4. D. Be left out entirely when the exam is normal
    Show answer

    Answer: B. Record relevant normal and abnormal findings

    Record relevant findings by body region. Normal findings prove assessment.

23. A pain assessment should document:

    1. A. Location, quality, severity, and change
    2. B. Only the numeric severity rating, 0 to 10
    3. C. Only the analgesic medication given and dose
    4. D. Only the location the patient points to now
    Show answer

    Answer: A. Location, quality, severity, and change

    Document location, quality, severity, radiation, and changes over time. Reassess after treatment.

24. Vital sign documentation includes:

    1. A. Values, time, and position when relevant
    2. B. Only the first complete set obtained on scene
    3. C. Only the numeric values, without any times
    4. D. Only the sets that fall outside normal limits
    Show answer

    Answer: A. Values, time, and position when relevant

    Orthostatic sets require position.

25. ECG documentation should include:

    1. A. Only the heart rate displayed on the monitor
    2. B. Only the rhythm name as you interpreted it
    3. C. Nothing, since the monitor stores the data
    4. D. Rhythm, rate, 12-lead findings, and the strip
    Show answer

    Answer: D. Rhythm, rate, 12-lead findings, and the strip

    Include the rhythm interpretation, rate, and any 12-lead findings, with a strip attached. Strips are part of the record.

26. Blood glucose documentation should include:

    1. A. Only the dextrose or glucose given for it
    2. B. Only the numeric reading from the meter
    3. C. Nothing when the reading is in normal range
    4. D. The value, time, treatment, and response
    Show answer

    Answer: D. The value, time, treatment, and response

    Hypoglycemia is a reversible cause, so the response to treatment matters.

27. Which entry is the most complete documentation of a medication given?

    1. A. "Fentanyl given for the patient's pain with good effect."
    2. B. "1412: Fentanyl 50 mcg IV by J. Ruiz. Pain 8/10 to 4/10; RR 16."
    3. C. "1412: Fentanyl IV given by crew; pt tolerated it well."
    4. D. "Pain medication per protocol; pt resting comfortably now."
    Show answer

    Answer: B. "1412: Fentanyl 50 mcg IV by J. Ruiz. Pain 8/10 to 4/10; RR 16."

    Medication documentation needs the time, drug, dose, route, who gave it, and the response, including reassessment for side effects such as respiratory depression. The other entries leave out the dose, the giver, or a measurable response, so no one can tell later whether the drug was appropriate, safe, or effective.

28. Procedures performed should be documented with:

    1. A. Only the time each procedure was started
    2. B. The procedure, time, attempts, and outcome
    3. C. The procedure name, without any further detail
    4. D. Only the attempts that ended in a success
    Show answer

    Answer: B. The procedure, time, attempts, and outcome

    Include the procedure, time, number of attempts, success, and any complications. Failed attempts too.

29. Response to treatment should be documented:

    1. A. Only when the change was dramatic or sudden
    2. B. Only when the patient's condition improved
    3. C. After every intervention, good or bad
    4. D. Once, as a summary at the end of the call
    Show answer

    Answer: C. After every intervention, good or bad

    Document after every intervention, whether improved, unchanged, or worsened. It shows the effect of care.

30. Reassessment should be documented:

    1. A. Only on arrival at the receiving hospital
    2. B. At intervals matching acuity, with times
    3. C. Only when the patient's condition has changed
    4. D. Once, after the first set of interventions
    Show answer

    Answer: B. At intervals matching acuity, with times

    Reassessment intervals should match patient acuity. Gaps suggest neglect.

31. The transport decision should be documented with:

    1. A. Only the name of the receiving hospital chosen
    2. B. Only the transport mode, such as lights and sirens
    3. C. Nothing, since dispatch records destination
    4. D. Destination, reason for choosing it, and mode
    Show answer

    Answer: D. Destination, reason for choosing it, and mode

    Bypassing a hospital needs justification.

32. Patient condition at transfer should be documented because:

    1. A. It replaces the need for a verbal hand-off
    2. B. It shows status when responsibility changed
    3. C. Billing requires it to support the transport claim
    4. D. Hospitals use it to assign the triage level
    Show answer

    Answer: B. It shows status when responsibility changed

    It establishes the patient's status when responsibility changed. Deterioration after transfer is then clearly attributed.

33. At the ED, the busy charge nurse accepts your patient's care but leaves before signing your ePCR. What is the best action?

    1. A. Document the nurse's name and time, and get a signature per policy
    2. B. Leave the patient in the hallway until someone agrees to sign
    3. C. Sign the nurse's name yourself so the record is complete
    4. D. Note 'ED staff' as the receiver and clear the hospital
    Show answer

    Answer: A. Document the nurse's name and time, and get a signature per policy

    The receiving signature, or at least the receiver's name and the time, proves care was handed to a qualified provider and not abandoned. Follow agency policy to get the signature, or document why you couldn't. Leaving the patient unattended over paperwork is unsafe. Signing for someone else is falsification. 'ED staff' doesn't show who accepted responsibility.

34. Crew members and their levels should be documented because:

    1. A. The level of care depends on who was present
    2. B. It is a tradition carried over from paper forms
    3. C. Dispatch needs it to assign the next call
    4. D. It replaces the need for each medic to sign
    Show answer

    Answer: A. The level of care depends on who was present

    The level of care provided depends on who was present. ALS billing requires a paramedic. Listing crew members does not take the place of the required signatures.

35. Mileage documentation is required for:

    1. A. Vehicle maintenance schedules
    2. B. Fuel purchase reconciliation
    3. C. Billing and transport records
    4. D. Crew payroll and time records
    Show answer

    Answer: C. Billing and transport records

    Accuracy matters for compliance.

36. Documentation of other agencies on scene:

    1. A. Gives context and identifies witnesses
    2. B. Is unnecessary in a patient care record
    3. C. Is done only when police are on the scene
    4. D. Is optional and left to the crew's discretion
    Show answer

    Answer: A. Gives context and identifies witnesses

    Unit numbers help later.

37. Documentation of equipment used, such as a cervical collar size:

    1. A. Is done only so supplies can be billed
    2. B. Supports clinical review and tracking
    3. C. Is unnecessary when the device worked well
    4. D. Is optional unless the device malfunctioned
    Show answer

    Answer: B. Supports clinical review and tracking

    It supports clinical review and equipment tracking. Also note equipment left with the patient.