CADS CADS Medical Terminology & Clinical Coding 2 — Questions and Answers
Question 1: The Glasgow Coma Scale (GCS) is documented using three components; which combination represents the maximum score of 15?
- Eye 4, Verbal 5, Motor 6 (Correct answer)
- Eye 3, Verbal 5, Motor 6
- Eye 4, Verbal 4, Motor 6
- Eye 4, Verbal 5, Motor 5
Correct answer: Eye 4, Verbal 5, Motor 6
A perfect GCS of 15 is achieved with Eye opening 4 (spontaneous), Verbal 5 (oriented), and Motor 6 (obeys commands).
Question 2: Which medical abbreviation is used in EMS documentation to indicate a patient's condition was unchanged during transport?
- UTNS (Correct answer)
- SOB
- AVPU
- ALS
Correct answer: UTNS
UTNS (Unchanged, Transport No Significant change) or similar notations indicate patient status remained stable during ambulance transport.
Question 3: When documenting pediatric respiratory distress, which term describes the visible inward movement of soft tissue between ribs during inhalation?
- Intercostal retractions (Correct answer)
- Subcutaneous emphysema
- Paradoxical breathing
- Kussmaul respirations
Correct answer: Intercostal retractions
Intercostal retractions refer to the visible sinking of skin between the ribs during labored breathing, a key sign of pediatric respiratory distress documented in PCRs.
Question 4: The OPQRST mnemonic used in EMS documentation stands for which set of assessment components?
- Onset, Provocation, Quality, Radiation, Severity, Time (Correct answer)
- Origin, Pain, Quality, Radiation, Signs, Treatment
- Onset, Pain, Query, Response, Severity, Transport
- Objective, Provocation, Quality, Region, Severity, Timeline
Correct answer: Onset, Provocation, Quality, Radiation, Severity, Time
OPQRST (Onset, Provocation, Quality, Radiation, Severity, Time) is the standard EMS mnemonic used to document a patient's chief complaint history in the PCR.
Question 5: In ICD-10-CM documentation, a 7th character 'A' appended to a trauma code indicates which encounter type?
- Initial encounter (Correct answer)
- Subsequent encounter
- Sequela
- Accidental injury
Correct answer: Initial encounter
The 7th character 'A' in ICD-10-CM trauma codes indicates the initial encounter, meaning the patient is receiving active treatment for the injury.
Question 6: Which NEMSIS data element captures the EMS agency's response to the scene?
- eTimes.06 (Correct answer)
- ePatient.01
- eDisposition.12
- eScene.01
Correct answer: eTimes.06
NEMSIS eTimes.06 captures the time the unit arrived at the scene, a critical timestamp used for response performance measurement and documentation compliance.
CADS CADS Medical Terminology & Clinical Coding 2
The Glasgow Coma Scale (GCS) is documented using three components; which combination represents the maximum score of 15?