When entering information into an official medical record, which of the following should NEVER be included?
A. Defaming remarks
B. Personal comments
C. Possible diagnoses
D. Personal opinions
E. All of the above
ANSWER: E
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You have been dispatched to a residence for a male patient with a cardiac history who is complaining of chest pain. On scene, you find a 52-year-old man sitting in a chair. He is alert and oriented. He states that his chest pain feels like the last time he had a heart attack. He reports that in the hospital his heart stopped and the health care personnel had to shock him twice before it restarted. He is breathing adequately and has a strong radial pulse. Which of these actions would be appropriate in the assessment and/or management of this patient?
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