CADS CADS Medical Terminology & Clinical Coding

Question 1

Which ICD-10-CM code category is used to document dyspnea as the primary complaint in an ambulance patient care report?

Accepted Answer

R06

Answer

ICD-10-CM category R06 covers abnormalities of breathing, including dyspnea, which is the appropriate code for respiratory complaints in PCR documentation.

Question 2

The abbreviation 'AMS' in EMS documentation refers to which clinical finding?

Accepted Answer

Altered Mental Status

Answer

AMS stands for Altered Mental Status, a common clinical finding documented in EMS patient care reports when a patient's level of consciousness is abnormal.

Question 3

When documenting a patient with ST-elevation myocardial infarction, which ICD-10-CM code block applies?

Accepted Answer

I21

Answer

ICD-10-CM code block I21 covers ST-elevation myocardial infarction (STEMI), the appropriate classification for acute heart attack with ST changes.

Question 4

Which medical term correctly describes the documentation finding 'absence of breath sounds on one side'?

Accepted Answer

Unilateral absence of breath sounds

Answer

Unilateral absence of breath sounds is the correct clinical term used in documentation when breath sounds are not heard on one side, often indicating pneumothorax or hemothorax.

Question 5

In NEMSIS-compliant documentation, the element 'ePatient.13' captures which data point?

Accepted Answer

Patient's date of birth

Answer

NEMSIS element ePatient.13 captures the patient's date of birth, a required demographic field in standardized EMS electronic patient care records.

CADS - Certified Ambulance Documentation Specialist Practice Test

CADS - Certified Ambulance Documentation Specialist Practice Test

CADS CADS Medical Terminology & Clinical Coding