CADS Medical Terminology & Clinical Coding Flashcards

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

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).

Which medical abbreviation is used in EMS documentation to indicate a patient's condition was unchanged during transport?

Answer: UTNS

UTNS (Unchanged, Transport No Significant change) or similar notations indicate patient status remained stable during ambulance transport.

When documenting pediatric respiratory distress, which term describes the visible inward movement of soft tissue between ribs during inhalation?

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.

The OPQRST mnemonic used in EMS documentation stands for which set of assessment components?

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.

In ICD-10-CM documentation, a 7th character 'A' appended to a trauma code indicates which encounter type?

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.

Which NEMSIS data element captures the EMS agency's response to the scene?

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.