Question

Documentation of your physical examination should be:

Select one:
a. representative of your perceptions.
b. factual and nonjudgemental.
c. reviewed by the ambulance service administration staff.
d. subjective in all regards.

Answer 1

Physical examination documentation should be factual and nonjudgemental, ensuring it is based on objective observations and free from personal biases.

Step-by-step explanation:

The documentation of your physical examination should be b. factual and nonjudgemental. This implies that the findings you record in the patient's notes must be based on objective evidence and should not reflect your personal opinions or biases. The information should be straightforward and should represent direct observations of the outcomes of tests and the patient's condition. For example, noting that a patient has reduced sensation in their left arm and leg based on your tests provides factual data on their sensory system's status without conveying any personal judgements. This approach ensures that your documentation can be utilized effectively by other healthcare professionals and that it contributes to high-quality patient care.