PCR Narrative Formats Practice Questions

30 multiple-choice questions on Narrative formats 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.

30 practice questions

1. In the SOAP format, the S stands for:

   1. A. Scene, describing what the crew found on arrival
   2. B. Subjective, what the patient and others report
   3. C. Signs, meaning the findings observed on exam
   4. D. Summary of the chief complaint and history
   Show answer

   Answer: B. Subjective, what the patient and others report

   SOAP is subjective, objective, assessment, and plan. Subjective is what the patient and others tell you.

2. In the SOAP format, objective information includes:

   1. A. The patient's own description of the pain
   2. B. The family's account of the events before 911
   3. C. Information relayed by dispatch about the call
   4. D. Measured findings such as vitals and the exam
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   Answer: D. Measured findings such as vitals and the exam

   Objective is what you observed and measured, such as vital signs and physical exam results.

3. In the CHART format, the A stands for:

   1. A. Airway, its status and any interventions
   2. B. Allergies to medications and other agents
   3. C. Assessment, your evaluation of the patient
   4. D. Actions, meaning the treatments performed
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   Answer: C. Assessment, your evaluation of the patient

   CHART is chief complaint, history, assessment, treatment (Rx), and transport.

4. The chronological narrative format describes:

   1. A. Events in order from arrival through transfer
   2. B. Only the interventions and when they occurred
   3. C. Findings grouped by body system, head to toe
   4. D. Only the assessment, without treatment detail
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   Answer: A. Events in order from arrival through transfer

   It reads naturally and is easy to follow.

5. The head-to-toe narrative style organizes information by:

   1. A. Treatment given
   2. B. Time sequence
   3. C. Body region
   4. D. Priority level
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   Answer: C. Body region

   It fits trauma patients well.

6. The most important consideration when choosing a narrative format is:

   1. A. The format that yields the shortest narrative
   2. B. A consistent, complete structure others can follow
   3. C. The format that is fastest to write after a call
   4. D. Whatever format the provider personally prefers
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   Answer: B. A consistent, complete structure others can follow

   Use a consistent, complete structure that another provider can follow. Consistency prevents omissions.

7. A good narrative begins by describing:

   1. A. The scene, patient position, and first impression
   2. B. The final field diagnosis and the reasoning behind it
   3. C. The billing level and the unit's response mode
   4. D. The transport decision and chosen destination
   Show answer

   Answer: A. The scene, patient position, and first impression

   Describe the scene, the patient's position, and the initial general impression. The reader should be able to picture what you walked into.

8. The narrative should end with:

   1. A. Transport, condition on arrival, and transfer
   2. B. The full crew roster and certification levels
   3. C. Your opinion of the patient's likely outcome
   4. D. A summary of the original dispatch information
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   Answer: A. Transport, condition on arrival, and transfer

   End with transport details, the patient's condition on arrival, and transfer of care. Close the loop on who took over care.

9. Restating every data field in the narrative is:

   1. A. Standard practice in most EMS documentation
   2. B. Required so the narrative stands on its own
   3. C. Helpful because billers read only narratives
   4. D. Unnecessary duplication of the data fields
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   Answer: D. Unnecessary duplication of the data fields

   Key values may be repeated for context, but use the narrative for the story and reasoning.

10. A narrative that says only "patient assessed and transported" is:

    1. A. Complete if every check box is filled in
    2. B. Acceptable for minor calls with normal findings
    3. C. Preferred because brevity reduces liability
    4. D. Inadequate, since it shows no assessment or care
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    Answer: D. Inadequate, since it shows no assessment or care

    It shows no assessment, findings, or care. The narrative carries the reasoning nothing else can.

11. The P in SOAP stands for:

    1. A. Patient history, including the SAMPLE items
    2. B. Pain, including OPQRST and its severity
    3. C. Pulse, including rate, rhythm, and quality
    4. D. Plan, including treatment and transport
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    Answer: D. Plan, including treatment and transport

    Plan covers treatment and transport. It also includes reassessment.

12. In a SOAP narrative, where does "Pt states she 'can't catch her breath' since 0300" belong?

    1. A. Objective
    2. B. Subjective
    3. C. Assessment
    4. D. Plan
    Show answer

    Answer: B. Subjective

    Subjective information is what the patient or bystanders report, including quoted symptoms and timing. Objective information is what you observe or measure, such as vitals, exam findings, and monitor data. Assessment is your field impression. Plan is the treatment and transport. Putting statements and findings in the right section keeps the narrative clear.

13. The A in SOAP is:

    1. A. Actions taken and the patient's response
    2. B. Airway status and any airway interventions
    3. C. Allergies to medications, foods, and latex
    4. D. Your field impression of the problem
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    Answer: D. Your field impression of the problem

    Assessment is your field impression, your clinical conclusion.

14. The C in CHART stands for:

    1. A. Care provided
    2. B. Circulation status
    3. C. Current condition
    4. D. Chief complaint
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    Answer: D. Chief complaint

    The patient's main problem.

15. The H in CHART stands for:

    1. A. Hand-off to receiving staff
    2. B. Head-to-toe exam findings
    3. C. History, present and past
    4. D. Heart rhythm and 12-lead
    Show answer

    Answer: C. History, present and past

    History covers the present illness and past history, including SAMPLE and OPQRST.

16. The R in CHART stands for:

    1. A. Reassessment findings
    2. B. Response to treatment
    3. C. Rx, meaning treatment
    4. D. Report given at hand-off
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    Answer: C. Rx, meaning treatment

    R stands for Rx, the treatment given. It is sometimes written as Rx.

17. The T in CHART stands for:

    1. A. Triage category assigned on scene
    2. B. Transport, destination and condition
    3. C. Times recorded for each intervention
    4. D. Treatment given and the patient response
    Show answer

    Answer: B. Transport, destination and condition

    Transport includes the destination and the condition on arrival. It is the final section.

18. The CHARTE format adds:

    1. A. Exceptions, such as refusals or deviations
    2. B. Equipment used and any device malfunctions
    3. C. Events in order from dispatch to the scene
    4. D. Evaluation of outcome after the transfer
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    Answer: A. Exceptions, such as refusals or deviations

    Exceptions covers unusual circumstances or deviations. Refusals and protocol deviations go here.

19. DRAATT is a format standing for:

    1. A. Dispatch, rhythm, airway, assessment, treatment, transport
    2. B. Destination, route, arrival, assessment, transfer, time
    3. C. Dispatch, response, arrival, assessment, treatment, transport
    4. D. Diagnosis, reason, action, assessment, time, transfer
    Show answer

    Answer: C. Dispatch, response, arrival, assessment, treatment, transport

    It follows the call chronologically.

20. The chronological format is well suited to:

    1. A. Calls where sequence matters, like arrests
    2. B. Detailed head-to-toe trauma examinations
    3. C. Refusals where little care was provided
    4. D. Routine transfers between two facilities
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    Answer: A. Calls where sequence matters, like arrests

    It suits calls where sequence matters, such as cardiac arrest. Times anchor each event.

21. The body systems format organizes findings by:

    1. A. Organ system
    2. B. Priority level
    3. C. Acuity level
    4. D. Time sequence
    Show answer

    Answer: A. Organ system

    It suits complex medical patients.

22. A narrative should always include:

    1. A. The crew's opinions about the patient's story
    2. B. Scene, findings, treatment, response, transfer
    3. C. Only the treatments given and their timing
    4. D. Only the assessment findings and vital signs
    Show answer

    Answer: B. Scene, findings, treatment, response, transfer

    Include the scene description, assessment findings, treatment, response, and transfer. It tells the complete story.

23. A narrative written entirely in abbreviations:

    1. A. Is efficient and is preferred by reviewers
    2. B. Is the expected standard in EMS charting
    3. C. Is hard to read and may be misinterpreted
    4. D. Is fine if each abbreviation is widely known
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    Answer: C. Is hard to read and may be misinterpreted

    Balance brevity and clarity.

24. A narrative that reads as a template with blanks:

    1. A. Suggests the assessment was not individualized
    2. B. Is preferred because it ensures completeness
    3. C. Is efficient and meets charting standards
    4. D. Is required by most electronic chart systems
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    Answer: A. Suggests the assessment was not individualized

    Each patient is different.

25. Electronic narratives benefit from:

    1. A. Structured fields plus free text for reasoning
    2. B. Auto-filled text generated from the data fields
    3. C. Copying the prior narrative for repeat patients
    4. D. Check boxes alone, with no free-text section
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    Answer: A. Structured fields plus free text for reasoning

    Reasoning cannot be captured in boxes.

26. The narrative should explain:

    1. A. The reasoning behind each key decision
    2. B. Only the time each intervention was performed
    3. C. Only the findings, leaving conclusions to MDs
    4. D. Only what was done, not the reasons behind it
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    Answer: A. The reasoning behind each key decision

    Explain why decisions were made, especially unusual ones. Reasoning defends decisions.

27. Negative findings in the narrative should be:

    1. A. Omitted, since only positive findings matter
    2. B. Avoided, since they invite legal questions
    3. C. Listed exhaustively for every body system
    4. D. Included when pertinent to the complaint
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    Answer: D. Included when pertinent to the complaint

    "Denies chest pain" in a dyspnea patient matters.

28. The narrative should describe the patient's position and appearance on arrival because:

    1. A. It sets the baseline for the general impression
    2. B. Billing uses it to justify a stretcher
    3. C. Agency policy requires it on every report
    4. D. It proves the scene was safe when the crew arrived
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    Answer: A. It sets the baseline for the general impression

    It sets the baseline and supports the general impression. "Found supine on the floor" tells a story. Position and appearance describe the patient, not scene safety.

29. A narrative should avoid:

    1. A. Direct quotes from the patient or family
    2. B. Pertinent negatives related to the complaint
    3. C. Speculation not supported by findings
    4. D. Exact times for interventions and vitals
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    Answer: C. Speculation not supported by findings

    Avoid speculating about causes your findings do not support. Document what you observed.

30. For a cardiac arrest with multiple rhythm changes, drugs, and shocks, which narrative approach is most useful to reviewers?

    1. A. Chronological, with times for each intervention and rhythm
    2. B. Head-to-toe, organized by body region
    3. C. SOAP, with all treatments grouped under Plan
    4. D. A brief summary, since the monitor stores the data
    Show answer

    Answer: A. Chronological, with times for each intervention and rhythm

    A resuscitation is judged on sequence and timing, such as time to first shock, epinephrine intervals, and ROSC, so a timed chronological narrative fits best. A head-to-toe layout cannot show sequence. Grouping every treatment under Plan loses the timeline. Monitor data helps, but it does not replace the narrative linking events, reasoning, and response.