Medical documentation is the record of healthcare provided to the patient at the healthcare facility, which may be in the form of handwritten or typed narratives, reported diagnostic results, diagnostic images or scans, or other records
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Health Professions
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You have been called to the house of a patient with altered mental status. You encounter a 41-year-old male who exhibits slurred speech, an unsteady gait, and has an odor of alcohol on his breath. His wife states that he is an alcoholic and needs help to get better. When documenting this, which one of the following would be best?
A) Alcoholic history disclosed to EMS B) Patient with history of alcoholism C) Family member states patient ETOH D) Per wife—patient with alcoholic history
Health Professions
If a cardiac arrest patient were in asystole ("flat line"), which of the following messages would the AED provide?
A) "Shock advised" B) "Check electrodes" C) "No shock advised" D) "Press analyze"
Health Professions