CADS CADS Medical Terminology & Clinical Coding 2

Question 1

The Glasgow Coma Scale (GCS) is documented using three components; which combination represents the maximum score of 15?

Accepted Answer

Eye 4, Verbal 5, Motor 6

Answer

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?

Accepted Answer

UTNS

Answer

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?

Accepted Answer

Intercostal retractions

Answer

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?

Accepted Answer

Onset, Provocation, Quality, Radiation, Severity, Time

Answer

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?

Accepted Answer

Initial encounter

Answer

The 7th character 'A' in ICD-10-CM trauma codes indicates the initial encounter, meaning the patient is receiving active treatment for the injury.

CADS - Certified Ambulance Documentation Specialist Practice Test

CADS - Certified Ambulance Documentation Specialist Practice Test

CADS CADS Medical Terminology & Clinical Coding 2