West Coast EMT Block One Exam

Which of the following statements is NOT appropriate to document in the narrative section of a PCR?

1. A. "The patient admits to smoking marijuana earlier in the day."

2. B. "Significant damage was noted to the front end of the vehicle."

3. C. "After oxygen was administered, the patient's breathing improved."

4. D. "General impression revealed that the patient was intoxicated."

The correct answer is: D. "General impression revealed that the patient was intoxicated."

In the context of patient care reports (PCRs), documentation should always be objective, factual, and based on observable evidence or findings. The correct answer is that the statement indicating the general impression of the patient being intoxicated is not appropriate to include in the narrative section of a PCR. This statement may seem subjective because it relies on the observer's interpretation rather than quantifiable data or direct indicators of intoxication. Intoxication as a diagnosis requires specific criteria and confirmation through assessment rather than a general impression. Including subjective remarks may introduce ambiguity or controversy in a medical record, as it can be challenged or misinterpreted. In contrast, the other statements are acceptable because they provide clear, factual information regarding the patient's condition, the actions taken, and the outcomes observed. Documenting the patient's admission to marijuana use offers relevant background information, significant damage to the vehicle describes the environmental context of the incident, and noting the improvement in the patient's breathing after oxygen administration details a medical assessment's outcome and response to treatment. These types of entries bolster the integrity and utility of the PCR by remaining within the realm of observable facts and actions taken in the care of the patient.