NREMT Emergency Medical Technician (EMT) Cognitive ExamEMS OperationsMedium
An EMT is completing a patient care report (PCR) for a patient with chest pain. The patient denies any past medical history, but the EMT observed a nitroglycerin patch on the patient's chest. What is the MOST appropriate way to document this discrepancy?
- ADocument 'Patient denies past medical history. Nitroglycerin patch observed on chest.'
- BDocument 'Patient denies past medical history' and remove the patch before transport.
- CDocument 'Patient is unreliable; nitroglycerin patch observed.'
- DDocument 'Patient denies past medical history' and omit the patch observation.
Show answer & explanationAnswer & explanation
Correct answer: A. Document 'Patient denies past medical history. Nitroglycerin patch observed on chest.'
Accurate and objective documentation includes both subjective patient statements and objective observations. Discrepancies should be noted factually, without judgment, allowing subsequent care providers to interpret the information.
Why the other options are wrong
- B. Removing medication without medical direction is outside the EMT's scope of practice and potentially harmful.
- C. Labeling a patient as 'unreliable' is subjective and judgmental, which is inappropriate for professional documentation.
- D. Omitting objective observations can lead to incomplete and potentially misleading documentation.
Objective vs. Subjective Documentation
Objective documentation includes factual, observable, and measurable data, while subjective documentation includes information directly stated by the patient or bystanders.
- Both types of information are crucial for a complete PCR.
- Discrepancies should be documented factually without judgment.
- Objective findings can include vital signs, physical exam findings, and observed medications.
Memory trick: Factual, Objective, Complete, Timely, and Legible documentation is key.