Patient Assessment & Documentation Flashcards

The 'E' in the OPQRST mnemonic used for pain assessment stands for:

Answer: Exacerbating and relieving factors

In OPQRST, 'E' stands for Exacerbating and relieving factors — what makes the pain better or worse.

You arrive on scene to find an unresponsive adult. After ensuring scene safety, your immediate next step is:

Answer: Establish responsiveness and call for help

The primary survey begins by checking responsiveness and activating the emergency response system before proceeding to airway and circulation.

Which term describes documentation that is altered or falsified after a patient care report has been submitted?

Answer: Falsification

Falsification refers to intentional alteration or fabrication of documentation, which is both unethical and illegal in EMS practice.

During a pediatric assessment using the Pediatric Assessment Triangle (PAT), which three components are evaluated?

Answer: Appearance, Work of Breathing, Circulation to skin

The PAT evaluates Appearance (tone, interactiveness, cry), Work of Breathing (retractions, sounds), and Circulation to skin (color, mottling) from a distance.

A patient's Glasgow Coma Scale score is calculated as Eyes=3, Verbal=4, Motor=5. What is the total GCS score?

Answer: 12

GCS is calculated by summing the three component scores: 3 (eyes) + 4 (verbal) + 5 (motor) = 12.

Which assessment tool uses mnemonic components including 'Onset, Provocation, Quality, Radiation, Severity, Time' to evaluate pain?

Answer: OPQRST

OPQRST is the standard EMS mnemonic used to comprehensively assess the characteristics of a patient's pain or chief complaint.

When performing a rapid trauma assessment, DCAP-BTLS is used to identify soft tissue injuries. What does the 'B' stand for?

Answer: Bleeding

In DCAP-BTLS, 'B' stands for Burns, which must be identified during the rapid head-to-toe trauma assessment.