NREMT Paramedic Cognitive ExamOperationsMedium
A paramedic is asked to review a patient care report (PCR) written by a new EMT. The report states, 'Patient appeared intoxicated and uncooperative.' Which of the following is the most appropriate feedback regarding this statement?
- AIt is important to document the patient's mental status, even if subjective.
- BThe statement is acceptable as it reflects the EMT's observation.
- CThe EMT should have used a direct quote from the patient instead.
- DThe statement uses subjective language and should be replaced with objective observations.
Show answer & explanationAnswer & explanation
Correct answer: D. The statement uses subjective language and should be replaced with objective observations.
Paramedic documentation should be objective, focusing on observable facts and avoiding subjective interpretations or judgments. Phrases like 'appeared intoxicated' or 'uncooperative' are subjective and should be replaced with specific, measurable observations.
Why the other options are wrong
- A. Mental status should be documented, but objectively (e.g., 'GCS 14,' 'oriented to person only,' 'agitated').
- B. While an observation, it is subjective and not ideal for professional documentation.
- C. Direct quotes are useful for patient statements, but not for describing the EMT's subjective interpretation of behavior.
Objective Documentation
Recording observable facts and measurable data without personal interpretation or judgment in patient care reports.
- Focuses on 'what you see, hear, feel, and smell.'
- Avoids assumptions, opinions, and subjective terms.
- Enhances legal defensibility and continuity of care.
Memory trick: Facts, not feelings, make a record appealing.