PCR Writing Style and Accuracy Practice Questions

37 multiple-choice questions on Writing style and accuracy 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. Objective documentation means recording:

   1. A. Your conclusions about the patient's condition
   2. B. Observable facts and direct quotations
   3. C. Your suspicions about the underlying cause
   4. D. The family's opinions about what happened
   Show answer

   Answer: B. Observable facts and direct quotations

   Record observable, measurable facts and direct quotations. Findings, not verdicts.

2. Which is an objective statement?

   1. A. Speech slurred; odor of alcoholic beverage noted
   2. B. Patient seemed anxious about going to hospital
   3. C. Patient was uncooperative throughout the call
   4. D. Patient was intoxicated and acting erratically
   Show answer

   Answer: A. Speech slurred; odor of alcoholic beverage noted

   Describe what you observed and let the reader draw conclusions.

3. The patient's own statements are best recorded:

   1. A. Word for word, in quotation marks
   2. B. As summarized by a family member present
   3. C. Paraphrased into clinical terminology
   4. D. Left out in favor of objective findings
   Show answer

   Answer: A. Word for word, in quotation marks

   Record key statements word for word in quotation marks. Quotes carry weight in both care and court.

4. Slang and derogatory terms in a report:

   1. A. Are unprofessional and damaging in court
   2. B. Are acceptable as long as they are accurate
   3. C. Add useful color and context to the narrative
   4. D. Are fine since most providers use them anyway
   Show answer

   Answer: A. Are unprofessional and damaging in court

   They are unprofessional, damaging in court, and can violate policy. Assume the patient will read it.

5. Abbreviations used in a report should be:

   1. A. Only those on the agency's approved list
   2. B. Any that are commonly known in medicine
   3. C. Those the writer defines in the narrative
   4. D. None, since all abbreviations are banned
   Show answer

   Answer: A. Only those on the agency's approved list

   Unapproved or ambiguous abbreviations cause errors.

6. Abbreviations such as U for units or QD for daily are discouraged because they:

   1. A. Take longer to write than the full word
   2. B. Are easily misread and have caused errors
   3. C. Are not recognized by billing software
   4. D. Are outdated but still technically valid
   Show answer

   Answer: B. Are easily misread and have caused errors

   They are easily misread and have caused medication errors; both appear on The Joint Commission's do-not-use list. Write out the word instead.

7. Spelling and legibility matter because:

   1. A. An unreadable record fails its purpose
   2. B. The state reviews them for license renewal
   3. C. They matter only for billing accuracy and coding
   4. D. Supervisors grade reports on presentation
   Show answer

   Answer: A. An unreadable record fails its purpose

   A record that cannot be read or understood fails its purpose and undermines credibility. In court, sloppy records suggest sloppy care.

8. Documenting a patient's race, religion, or lifestyle is appropriate only when:

   1. A. It gives helpful context about the patient
   2. B. It is clinically relevant to the care
   3. C. Law enforcement asks for it to be included
   4. D. The crew considered it notable at the time
   Show answer

   Answer: B. It is clinically relevant to the care

   Include it only when clinically relevant to the care provided. Irrelevant details invite bias claims.

9. Documenting that the patient "refused to cooperate" is:

   1. A. The preferred phrasing for later legal review
   2. B. Required wording whenever a patient resists
   3. C. Sufficient to document the patient's behavior
   4. D. Better replaced with specific behaviors
   Show answer

   Answer: D. Better replaced with specific behaviors

   Record what the patient said and did. Specifics let the reader judge the situation.

10. Times documented in the narrative should:

    1. A. Be omitted, since the fields hold the times
    2. B. Be approximate, since exact times are unknown
    3. C. Be rounded to the nearest quarter hour for clarity
    4. D. Match times elsewhere and in dispatch records
    Show answer

    Answer: D. Match times elsewhere and in dispatch records

    Times must match those recorded elsewhere in the report and in dispatch records. Inconsistent times are a favorite target in litigation.

11. Recording a patient's medication list should include:

    1. A. Names, doses, and adherence when known
    2. B. Prescriptions only, not over-the-counter drugs
    3. C. Only the medications you administered on scene
    4. D. Names only, since doses can be looked up
    Show answer

    Answer: A. Names, doses, and adherence when known

    Include names, doses, and whether the patient has been taking them as prescribed. Bring the bottles or a photo when possible.

12. Documentation of a call involving a possible crime should be:

    1. A. Written to help identify the likely offender
    2. B. Brief, to avoid being called as a witness
    3. C. Factual, recording what was seen and said
    4. D. Left entirely to law enforcement to document
    Show answer

    Answer: C. Factual, recording what was seen and said

    Record what was observed and stated without conclusions. Also record anything you moved or altered at the scene.

13. First person versus third person in narratives:

    1. A. Both, switching between sections as needed
    2. B. Either, per agency convention, used consistently
    3. C. Only first person, since you wrote the report
    4. D. Only third person, since it sounds objective
    Show answer

    Answer: B. Either, per agency convention, used consistently

    Follow policy and stay consistent within the report.

14. Sentences in a narrative should be:

    1. A. Descriptive and literary
    2. B. Short, clear, and specific
    3. C. Fragmentary, like a checklist
    4. D. Long, with complex clauses
    Show answer

    Answer: B. Short, clear, and specific

    Clarity beats style.

15. Which is the better documentation?

    1. A. Patient seemed off and not acting normally
    2. B. Patient was very anxious and visibly upset
    3. C. Patient was difficult and demanding throughout
    4. D. Pacing, wringing hands, says 'I'm going to die'
    Show answer

    Answer: D. Pacing, wringing hands, says 'I'm going to die'

    Observations, not labels. Quote what the patient said, such as "I feel like I am going to die."

16. Which is the better documentation of a wound?

    1. A. Laceration present on the upper extremity
    2. B. 4 cm linear laceration, lateral left forearm
    3. C. Injury to the arm, bandaged on scene
    4. D. Big cut on the arm that was bleeding a lot
    Show answer

    Answer: B. 4 cm linear laceration, lateral left forearm

    Record size, type, location, and status, such as bleeding controlled.

17. Which is the better documentation of mental status?

    1. A. Oriented to person, place, time, and event
    2. B. Awake and alert, seems to be at baseline
    3. C. Mental status within normal limits today
    4. D. Alert and oriented, acting appropriately
    Show answer

    Answer: A. Oriented to person, place, time, and event

    Specific orientation, plus whether the patient follows commands, supports later comparison.

18. Documenting a patient as intoxicated:

    1. A. Preferred because it is concise and clear
    2. B. A conclusion; describe the signs instead
    3. C. Required whenever alcohol use is suspected
    4. D. Objective when an odor of alcohol is present
    Show answer

    Answer: B. A conclusion; describe the signs instead

    Describe odor, speech, gait, and behavior instead. Head injury and hypoglycemia mimic intoxication.

19. Which entry best documents a combative patient?

    1. A. "Pt swung fists at crew, yelled 'get away,' pulled off SpO2 twice."
    2. B. "Pt was uncooperative and hostile with the crew throughout the call."
    3. C. "Pt was combative, most likely due to being drunk at the time."
    4. D. "Pt was difficult; care was limited by the patient's attitude."
    Show answer

    Answer: A. "Pt swung fists at crew, yelled 'get away,' pulled off SpO2 twice."

    Objective documentation records specific behaviors and exact quotes, so readers can judge the situation for themselves and the record supports any restraint or limits on care. 'Uncooperative,' 'difficult,' and 'attitude' are labels. Calling him drunk is an unsupported conclusion, and combativeness may come from hypoxia, hypoglycemia, or a head injury.

20. Documenting a patient as faking:

    1. A. Is honest if the exam findings are normal
    2. B. Is required when symptoms seem inconsistent
    3. C. Is a label that invites defamation claims
    4. D. Is common and acceptable among providers
    Show answer

    Answer: C. Is a label that invites defamation claims

    It is a judgment that may be wrong and invites defamation claims. Describe inconsistencies without labeling.

21. Abbreviations such as SOB:

    1. A. May be misread; many prefer 'dyspnea'
    2. B. Are clear in any clinical context they appear
    3. C. Are universal and understood by all readers
    4. D. Are required by the national EMS data set
    Show answer

    Answer: A. May be misread; many prefer 'dyspnea'

    SOB may be misread or seem insulting, so many agencies prefer dyspnea. Context matters.

22. Writing out units of measure:

    1. A. Is required only for pediatric doses
    2. B. Is unnecessary for standard doses
    3. C. Prevents misreading of doses
    4. D. Is optional if handwriting is clear
    Show answer

    Answer: C. Prevents misreading of doses

    Write units rather than U.

23. A leading zero before a decimal dose:

    1. A. Is prohibited by most drug references
    2. B. Is confusing and should be left off
    3. C. Should always be used, as in 0.5 mg
    4. D. Is optional if the decimal is clear
    Show answer

    Answer: C. Should always be used, as in 0.5 mg

    Without it, .5 may be read as 5.

24. A trailing zero after a whole number dose:

    1. A. Should be used to show the dose is precise
    2. B. Is optional when the handwriting is clear
    3. C. Is required on all whole-number doses given
    4. D. Should never be used; 5.0 may read as 50
    Show answer

    Answer: D. Should never be used; 5.0 may read as 50

    Write 5 mg.

25. Time documentation should use:

    1. A. 12-hour time with AM or PM written out
    2. B. Any format, as long as it is legible to others
    3. C. The agency's standard, often 24-hour time
    4. D. Approximate times rounded to five minutes
    Show answer

    Answer: C. The agency's standard, often 24-hour time

    Consistency prevents AM/PM confusion.

26. Spelling errors in drug names:

    1. A. Are common and corrected by pharmacy
    2. B. Can confuse similar-looking drugs
    3. C. Are harmless if the dose is correct
    4. D. Are acceptable on handwritten reports
    Show answer

    Answer: B. Can confuse similar-looking drugs

    They can cause dangerous confusion between similar drugs. Look-alike names are a known hazard.

27. A patient who overdosed tells you, "I wanted to end it all." How should you document this?

    1. A. Pt is suicidal.
    2. B. Pt states, "I wanted to end it all."
    3. C. Pt made a vague comment about life.
    4. D. Pt may have been joking about self-harm.
    Show answer

    Answer: B. Pt states, "I wanted to end it all."

    Exact quotations preserve the patient's meaning and support decisions such as a psychiatric hold or a refusal not being accepted. 'Suicidal' is your conclusion, which belongs in the impression. Paraphrasing it as vague or as a joke downplays a statement that clinicians and the courts rely on.

28. Documentation of family statements should:

    1. A. Be omitted, since they are only hearsay
    2. B. Be paraphrased without naming the source
    3. C. Be recorded as the patient's statements
    4. D. Note the source and quote where helpful
    Show answer

    Answer: D. Note the source and quote where helpful

    For example: "Per daughter, patient fell at 0300."

29. Documenting a suspicion of abuse should:

    1. A. State clearly that abuse occurred in the home
    2. B. Be objective and note the report made
    3. C. Name the person the crew suspects of abuse
    4. D. Be left out until law enforcement confirms it
    Show answer

    Answer: B. Be objective and note the report made

    Describe findings and statements objectively and note the mandated report you made. Investigators conclude; you observe.

30. Documenting a protocol deviation should include:

    1. A. A note asking the supervisor to review it
    2. B. Only a statement that a deviation occurred
    3. C. The reason, medical control contact, and response
    4. D. Nothing, since deviations go on incident forms
    Show answer

    Answer: C. The reason, medical control contact, and response

    Explained deviations are defensible.

31. Documenting medical control orders should include:

    1. A. Physician, order, time, and the read-back
    2. B. Only the time the order was received by radio
    3. C. Only the name of the drug that was ordered
    4. D. Nothing, since the radio call is recorded
    Show answer

    Answer: A. Physician, order, time, and the read-back

    Include the physician's name, the order, the time, and that it was repeated back. Complete the chain.

32. Documenting a patient's belongings:

    1. A. Is unnecessary for a medical record
    2. B. Lists items and who received them
    3. C. Is optional unless items are valuable
    4. D. Is done only when police request it
    Show answer

    Answer: B. Lists items and who received them

    Listing items and who received them prevents disputes. Wallets and jewelry are common disputes.

33. Documentation of refusal of a specific intervention should include:

    1. A. The patient's signature and nothing further
    2. B. Only a statement that the patient refused it
    3. C. What, why, risks, and the care that continued
    4. D. Nothing, if the other care was accepted
    Show answer

    Answer: C. What, why, risks, and the care that continued

    Document what was refused, why the patient refused, the risks explained, and that care continued otherwise. Partial refusals are common.

34. Documentation of pediatric patients should include:

    1. A. Weight, caregiver, consent, and age-based vitals
    2. B. The caregiver's name and contact information
    3. C. Age only, since weight can be estimated later
    4. D. Vital signs only, compared with adult norms
    Show answer

    Answer: A. Weight, caregiver, consent, and age-based vitals

    Include weight, the caregiver present, the consent source, and age-appropriate vital signs. Weight drives dosing.

35. Documentation of geriatric patients should include:

    1. A. Age and living situation, without further detail
    2. B. Only the diagnoses listed in prior records
    3. C. Baseline function, medications, and caregiver
    4. D. Vital signs only, since history is unreliable
    Show answer

    Answer: C. Baseline function, medications, and caregiver

    Change from baseline is the finding.

36. Documentation of a patient's primary language and interpreter use:

    1. A. Is unnecessary if family can translate
    2. B. Is collected only for billing and coding
    3. C. Supports care and access compliance
    4. D. Is optional unless the patient requests it
    Show answer

    Answer: C. Supports care and access compliance

    It supports both care and compliance with language access requirements. Note who interpreted.

37. Readability of a report is improved by:

    1. A. Using more abbreviations to save space
    2. B. Writing longer, more detailed narratives
    3. C. Logical order and clear sentences
    4. D. Adding the provider's opinions for context
    Show answer

    Answer: C. Logical order and clear sentences

    Logical order, clear sentences, and a consistent format help. The reader should never be confused.