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National Registry Paramedic Examination Specifications
About the Paramedic Examination Specifications
The “National Registry Paramedic Examination Specifications” provides important information about the
Paramedic Certification Examination for stakeholders, such as current candidates, Emergency Medical
Services (EMS) students, and EMS educators. The Paramedic Certification Examination will be
administered starting July 1, 2024. This document outlines the content of the examination, as
determined through the 2019 National EMS Practice Analysis and 2021 National EMS Practice Analysis
Addendum and provides information regarding the development and administration of the examination.
Also included are sample items and information about the item development process.
Examination Purpose
The aim of the Paramedic Certification Examination is to determine whether EMS professionals at this
provider level can demonstrate the entry-level knowledge, skills, and abilities required to competently
perform their job. It is the expectation that a newly certified paramedic can:
• Provide safe and effective care with medical oversight through the integration of cognitive,
psychomotor, and affective processes in various patient care presentations.
• Assess each scene to determine the safety of all individuals present at the scene.
• Assess the patient to identify threats to life and limb and implement care to reduce morbidity
and mortality.
• Use fundamental knowledge of anatomy, physiology, and kinematics to identify concomitant
injuries and reduce loss of life and limb.
• Apply fundamental knowledge of anatomy, pathophysiology, pharmacology, emergency
cardiovascular care, and the etiology of disease processes to determine appropriate patient
interventions and transportation destinations that will promote a positive patient.
Development of the Test Plan
The Paramedic Certification Examination has evolved over the past four decades to become the most
valid, reliable, and respected measurement tool employed by millions of EMS providers nationwide in
their quest to attain National Paramedic Certification. In order to ensure the examination measures
current practice, the National Registry conducts practice analysis studies to identify the knowledge,
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skills, and abilities (KSAs) required in the EMS practice settings. The information gathered by practice
analysis studies is then used to determine the content of the examinations, also known as a “test plan.”
The 2019 National EMS Practice Analysis examined the knowledge needed for the paramedic as it
related to patient impression data. The patient presentations followed the historical division of four
areas: 1) Airway, Respiration & Ventilation, 2) Cardiology & Resuscitation, 3) Trauma, and 4)
Medical/Obstetrics/Gynecology. Additionally, the study explored the domain of EMS Operations.
Based on the results of the 2019 National EMS Practice Analysis and additional feedback from the EMS
community, in 2019 the National Registry’s Board of Directors undertook an initiative, “Advanced Life
Support (ALS) Assessment Redesign,” which was intended to improve the processes of assessing entry-
level competency using technology and emerging practices in the testing industry. As a part of the ALS
redesign initiative, one major change to the program was to discontinue the existing psychomotor
examination and embed new content into the cognitive examination that measures the critical skills of
communication, leadership, and clinical judgment. This new domain, Clinical Judgment, was defined
through the 2021 National EMS Practice Analysis Addendum.
Content for the Paramedic Certification Examination
Cognitive Domains
The 2019 National EMS Practice Analysis evaluated clinical impressions for the five areas, or “domains,”
which were described above. Tasks performed by the provider for these domains were also determined.
These five domains are collectively referred to as the “cognitive domains”:
1. Airway, Respiration, & Ventilation
2. Cardiology & Resuscitation
3. Trauma
4. Medical, Obstetrics & Gynecology
5. EMS Operations
Clinical Judgment
In accordance with the findings of the 2021 Practice Analysis Addendum and subject-matter expert (SME)
recommendations, the clinical judgment domain also samples information from two additional knowledge
areas, communication and leadership in an EMS response, as well as from each step of the processing
information cycle (Gugiu, McKenna, Platt, & Panchal, 2022). The steps of the processing information cycle
are: (a) recognize cues, (b) analyze cues, (c) define hypothesis, (d) generate solutions, (e) take action, and
(f) evaluation. As the EMS clinician moves from each setting within the EMS response, they re-evaluate
and move through the processing information cycle again.
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The Clinical Judgment domain is illustrated in the figure below:
Content Outline
The cognitive domains and the domain of Clinical Judgment collectively form the basis of the Paramedic
Certification Examination. The content of each domain was determined through the 2019 National EMS
Practice Analysis and 2021 Practice Analysis Addendum. An overview of the knowledge areas that are
sampled on the examination for each content domain is presented below:
Content Domain
Knowledge Areas Sampled
Airway, Respiration & Ventilation
• Assessment
• Pathophysiology
• Management
Cardiology & Resuscitation
• Assessment
• Pathophysiology
• Management
Trauma
• Assessment
• Pathophysiology
• Management
Medical/Obstetrics/Gynecology
• Assessment
• Pathophysiology
• Management
EMS Operations
• Maintenance & operation of emergency vehicles and
equipment
• Leadership & professionalism
• Communication & documentation
• Preservation of medical & legal standards
• Environment of care
Clinical Judgment
• Communication
• Leadership
• Recognize cues
• Analyze cues
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• Define hypothesis
• Generate solutions
• Take action
• Evaluation
Content Distribution for the Paramedic Certification Examination
The percentage of test questions aligned to each domain was determined through a statistical analysis
of data collected through the 2019 National EMS Practice Analysis and 2021 Practice Analysis Addendum
such that topics most critical for patient care are weighted more heavily. The percentage of the exam
allocated to each content domain is presented below:
Content Domain
Percent of Examination
Airway, Respiration & Ventilation *
8% – 12%
Cardiology & Resuscitation* **
10% – 14%
Trauma *
6% – 10%
Medical/Obstetrics/Gynecology*
24% – 28%
EMS Operations
8% – 12%
Clinical Judgment*
34% – 38%
* Note: items related to pediatric patient care will be integrated throughout the examination content.
** Note: 30% of the Cardiology & Resuscitation domain is allotted to graphical items with ECG rhythm strips.
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Item Development
The examination development process follows multiple steps. Examination items are developed to
measure each of the content areas described in the test plan. Every examination item is written by an
SME in EMS who is trained in item-writing best practices and techniques. These experts also reference
each item to industry-standard source materials.
The Examinations team then performs several rounds of internal review of each item for clinical
accuracy, factual correctness, clarity, adherence to style guidelines, and reference completeness. Next, a
committee of external SMEs reviews each item for accuracy, correctness, relevance, currency, and
proper scope of practice. Items are then reviewed again by internal staff for final confirmation of
adherence to all accuracy, quality, and stylistic standards.
The entire process to develop an examination item can take six months or longer from start to finish.
Following the reviews, each item is piloted. That is, the item is placed as an unscored item on an
examination to collect additional data to ensure the item is psychometrically sound before placement as
a scored item in a future examination.
Examination Administration
Computerized Adaptive Testing (CAT)
The Paramedic Certification Examination is administered through a Computerized Adaptive Testing
(CAT) format. CAT examinations are delivered in a different manner than fixed-length exams. After an
initial set of items, the computer will begin to administer items that are targeted at or above the
candidate’s estimated level of ability.
Because the computer delivers items that are more aligned with the candidate’s level of understanding,
it can determine candidate proficiency in a fewer number of items in many cases. If the computer can
make a pass/fail determination in the minimum number of items with 95% confidence, the test
administration will end. In some circumstances, it may take longer, and the computer will continue to
administer items until the maximum number of items is reached or the maximum time allotted is
reached.
Examination Length
Candidates have 3.5 hours to complete the Paramedic Certification Examination. The examination is
administered in Pearson VUE testing centers. Candidates will be required to answer a minimum of 110
items.
Unscored Content
The examination includes 20 unscored pilot items. These items are included in the examination for
purposes of collecting data to determine if the quality of the question meets the requirements to move
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forward on a future examination as a scored item. These items are not identified and will not affect a
candidate’s score.
Item Types
The Paramedic Certification Examination includes a variety of item types. All items are scored
dichotomously; that is, candidates receive full credit for a correct response. No credit is provided for a
partially correct response. These item types are described below:
• Multiple-choice: Candidates must select one correct response out of four possible options.
• Multiple-response: Candidates must select two or three correct responses out of five or six
possible options.
• Build List: Candidates must position several presented options into the order specified in the
item instructions.
• Drag-and-Drop: Candidates must position several presented options into certain categories,
classifications, or other identifiers as specified in the item instructions.
• Options Box: Candidates must classify, categorize, or identify several options presented in a
table based on certain specified criteria.
• Graphical: Candidates must use information provided in graphical form to answer the item.
Examples of the graphics presented include charts, ECG rhythm strips, images, and pictures.
Graphics may be included in any of the above item types.
• Scenario-Based: Candidates answer multiple questions based on information contained in a
“scenario” or reading passage. Scenario-based items may be any of the above types.
Sample Items
Sample items for the variety of item types are provided in Appendix A.
Passing Standard
The passing standard is the level of knowledge or ability that a competent EMS provider must
demonstrate to achieve a passing score on the examination. The passing standard is determined
through a standard-setting study, a formal qualitative process in which a trained psychometrician
facilitates the collection of data provided by a representative panel of nationally based SMEs from the
EMS workforce. The result of this study is a recommended cut score that is provided to the National
Registry Board of Directors along with additional data for consideration regarding the impact on the
EMS community and the public.
After the standard is approved by the Board of Directors, it is uniformly applied to all candidates. The
passing standard is reviewed each time new examination specifications are implemented.
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Appendix A: Sample Items
Multiple-Choice Item
Multiple-Response Item
Graphical Item
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Scenario-Based Item
The following Drag and Drop, Build List, and Options Box examples are all scenario-based items, as shown
above. Only the item itself is shown here to better illustrate each item type.
Drag-and-Drop Item
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Build List Item
Options Box Item
