NREMT Paramedic Cognitive ExamOperationsEasy
A paramedic is completing a patient care report (PCR) for a 55-year-old male who experienced a syncopal episode. The paramedic documented that the patient 'appeared to be malingering due to lack of objective findings.' This statement is an example of which of the following documentation errors?
- ALack of conciseness
- BInclusion of subjective opinion
- COmission of pertinent negatives
- DFailure to use medical terminology
Show answer & explanationAnswer & explanation
Correct answer: B. Inclusion of subjective opinion
Documenting that a patient 'appeared to be malingering' is a subjective opinion and a judgment about the patient's intent, which should not be included in objective medical documentation. PCRs should focus on observable facts and objective findings.
Why the other options are wrong
- A. The statement itself is concise, but its content is inappropriate.
- C. The error is not about what was left out, but what was inappropriately included.
- D. Malingering is a medical term, but its use here is as a subjective accusation rather than an objective finding.
Objective Documentation
Recording observable facts, patient statements, and measurable data without personal opinions or judgments.
- Focus on what you see, hear, smell, and touch.
- Use direct quotes for patient statements.
- Avoid assumptions, biases, or character judgments.
Memory trick: Just the Facts, Ma'am, No Opinions.