Ch 4, 5, 6

Front 1

Minumum Data Set

Back 1

Information the DOT requires on all PCRs

Front 2

Patient Information (MDS)

Back 2

Chief Complaint

AVPU (unresponsiveness)

Blood Pressure (greater than 3 y/o)

Skin Perfusion (less than 6 y/o)

Skin Color, Temp, and Condition

Pulse Rate

Respiratory Rate and Effort

Patient Demographics

Front 3

Administrative Information (MDS)

Back 3

Time..

the incident was reported

the unit was notified

of arrival at the patient

the unit left the scene

the unit arrived at its destination

of transfer of care

Front 4

Functions of the PCR

Back 4

Continuity of Medical Care

Administrative Uses

Legal Uses

Education and Research

Continuous Quality Improvement (CQI)

Front 5

Two Basic Rules of PCRs

Back 5

If it wasn't written down, it wasn't done.

If it wasn't done, don't write it down.

Front 6

Pertinent Negatives

Back 6

Signs or symptoms that might be expected, based on the chief complaint, but that the patient declines having.

Front 7

PCR Vitals

Back 7

Two sets of vital signs are needed

Record patient's position when vitals were obtained

Document the time vitals were obtained

Front 8

Treatment

Back 8

Detail in chronological order

Document the time of each treatment and the patient's response to each treatment.

Front 9

Refusal of Treatment

Back 9

Obtain as much information as possible to try to persuade the patient to accept care

Inform the patient of consequences if he/she refuses

Determine patient's competence to refuse care

Contact medical direction as needed

Document your assessment findings, emergency care that you provided, and your explanation to the patient about the consequences

Sign refusal form (patient and witness)

If the patient refuses to sign, obtain a signature from a witness

Advise patient of alternative ways to obtain transportation and care

Explain signs and symptoms that could indicate his condition is worsening

Call 911 if changed mind

Front 10

Correcting Errors

Back 10

Draw a single line through mistake

Provide correct info

Initial, date, and time of correction

Front 11

SOAP

Back 11

Format for Narrative Doc.

Subjective (symptoms)

Objective (observations)

Assessment (evaluation of S&O)

Plan (treatment provided)

Front 12

CHART

Back 12

Format for Narrative Doc.

Chief Complaint (reason for seeking care)

History (SAMPLE)

Assessment (findings from Primary/Secondary assessments and physical exam)

Rx (treatment that was provided)

Transport (any change in the patient's condition en route and the type of transport)

Front 13

CHEATED

Back 13

Format for Narrative Doc.

Chief Complaint

History

Exam (information from physical exam)

Assessment (field impression you derive by processing the history and physical exam findings and determining a condition)

Treatment

Evaluation (information found during the ongoing assessment and any identified improvement or deterioration of the patient's condition

Disposition (the transfer of patient care at the medical facility or to another health care provider

Front 14

SAMPLE

Back 14

Symptoms (What symptoms are you experiencing?)

Allergies (Do you have any allergies?)

Medications (Are you taking any medications?)

Past Medical History

Last Oral Intake (What was the last thing you ate?)

Events that lead to the problem (What were you doing when the pain began?)

Front 15

OPQRST

Back 15

Onset (When and how did the pain start?)

Provocation (Does anything make it feel better or worse?)

Quality (Describe the pain to me.)

Radiation (Where else do you hurt?)

Severity (Pain on a scale of 1-10)

Time (How long have you had these symptoms?)

Front 16

DCAP-BTLS

Back 16

Deformity (unusual shape)

Contusions (black and blue)

Abrasions (scrapes)

Punctures (stab/gunshot wound)

Burns/Bruises

Trauma

Lacerations (cuts)

Swelling

Front 17

T.I.C

Back 17

Tenderness (pain on touch)

Instability (wobbly arm/unstable)

Crepitus (rubbing bone sound)

Front 18

AVPU

Back 18

Levels of responsiveness

Alert (name, location, events)

Verbal Response (Look at you in response to speaking to them)

Pain Response (Moans/groans or visibly reacting to pain when pinched)

Unresponsive

Front 19

Open-ended Questions

Back 19

Questions that allow the patient to give a detailed response in his own words. Provides you with the most information. (What seems to be the problem?, How are you feeling?)

Front 20

Closed-ended Questions

Back 20

Questions that call for specific information from the patient. Yes or no questions: Are you having pain? When did the pain begin?

Front 21

SBAR

Back 21

Used to organize information into a standard format that would be useful when communicating with medical direction.

Situation - problem or reason why you are calling and patient's chief complaint.

Background - a concise description of the past medical history and the patient's response to treatment to that point

Assessment - includes pertinent subjective and objective assessment findings such as mental status, vital signs, neurological findings, glucose level, and Glasglow Coma Score.

Recommendation - what you are requesting for the patient, such as an order to administer another nitroglycerin spray.

Front 22

SBAR

Back 22

Used to organize information into a standard format that would be useful when communicating with medical direction.

Situation - problem or reason why you are calling and patient's chief complaint.

Background - a concise description of the past medical history and the patient's response to treatment to that point

Assessment - includes pertinent subjective and objective assessment findings such as mental status, vital signs, neurological findings, glucose level, and Glasglow Coma Score.

Recommendation - what you are requesting for the patient, such as an order to administer another nitroglycerin spray.

Front 23

Oral Report

Back 23

Turning the patient over to staff report.

Chief complaint

Vital signs taken en route

Treatment given en route and response to it

Pertinent history not given in the earlier report to the facility

Front 24

Oral Report

Back 24

Turning the patient over to staff report.

Chief complaint

Vital signs taken en route

Treatment given en route and response to it

Pertinent history not given in the earlier report to the facility

Front 25

FCC

Back 25

Has jurisdiction over all radio operations, including those used by EMS systems.

Licenses individual base station operations

Assigns radio call signs

Approves equipment for use

Assigns radio frequencies

Monitors field operations

Front 26

Break (Radio Term)

Back 26

Afford a "pause" so that the hospital can respond or interrupt if necessary.

Front 27

Break (Radio Term)

Back 27

Afford a "pause" so that the hospital can respond or interrupt if necessary.

Front 28

Clear (Radio Term)

Back 28

End of transmission

Front 29

Break (Radio Term)

Back 29

Afford a "pause" so that the hospital can respond or interrupt if necessary.

Front 30

Clear (Radio Term)

Back 30

End of transmission

Front 31

Come in (Radio Term)

Back 31

Requesting acknowledgement of transmission

Front 32

Break (Radio Term)

Back 32

Afford a "pause" so that the hospital can respond or interrupt if necessary.

Front 33

Clear (Radio Term)

Back 33

End of transmission

Front 34

Come in (Radio Term)

Back 34

Requesting acknowledgement of transmission

Front 35

Copy (Radio Term)

Back 35

Message received and understood

Front 36

Break (Radio Term)

Back 36

Afford a "pause" so that the hospital can respond or interrupt if necessary.

Front 37

Clear (Radio Term)

Back 37

End of transmission

Front 38

Come in (Radio Term)

Back 38

Requesting acknowledgement of transmission

Front 39

Copy (Radio Term)

Back 39

Message received and understood

Front 40

ETA (Radio Term)

Back 40

Estimated time of arrival

Front 41

Break (Radio Term)

Back 41

Afford a "pause" so that the hospital can respond or interrupt if necessary.

Front 42

Clear (Radio Term)

Back 42

End of transmission

Front 43

Come in (Radio Term)

Back 43

Requesting acknowledgement of transmission

Front 44

Copy (Radio Term)

Back 44

Message received and understood

Front 45

ETA (Radio Term)

Back 45

Estimated time of arrival

Front 46

Go Ahead (Radio Term)

Back 46

Proceed with your message

Front 47

Break (Radio Term)

Back 47

Afford a "pause" so that the hospital can respond or interrupt if necessary.

Front 48

Clear (Radio Term)

Back 48

End of transmission

Front 49

Come in (Radio Term)

Back 49

Requesting acknowledgement of transmission

Front 50

Copy (Radio Term)

Back 50

Message received and understood

Front 51

ETA (Radio Term)

Back 51

Estimated time of arrival

Front 52

Go Ahead (Radio Term)

Back 52

Proceed with your message

Front 53

Landline (Radio Term)

Back 53

Refers to telephone communications

Front 54

Break (Radio Term)

Back 54

Afford a "pause" so that the hospital can respond or interrupt if necessary.

Front 55

Clear (Radio Term)

Back 55

End of transmission

Front 56

Come in (Radio Term)

Back 56

Requesting acknowledgement of transmission

Front 57

Copy (Radio Term)

Back 57

Message received and understood

Front 58

ETA (Radio Term)

Back 58

Estimated time of arrival

Front 59

Go Ahead (Radio Term)

Back 59

Proceed with your message

Front 60

Landline (Radio Term)

Back 60

Refers to telephone communications

Front 61

Over (Radio Term)

Back 61

End of message, awaiting reply

Front 62

Break (Radio Term)

Back 62

Afford a "pause" so that the hospital can respond or interrupt if necessary.

Front 63

Clear (Radio Term)

Back 63

End of transmission

Front 64

Come in (Radio Term)

Back 64

Requesting acknowledgement of transmission

Front 65

Copy (Radio Term)

Back 65

Message received and understood

Front 66

ETA (Radio Term)

Back 66

Estimated time of arrival

Front 67

Go Ahead (Radio Term)

Back 67

Proceed with your message

Front 68

Landline (Radio Term)

Back 68

Refers to telephone communications

Front 69

Over (Radio Term)

Back 69

End of message, awaiting reply

Front 70

Repeat/say again (Radio Term)

Back 70

Did not understand message

Front 71

Break (Radio Term)

Back 71

Afford a "pause" so that the hospital can respond or interrupt if necessary.

Front 72

Clear (Radio Term)

Back 72

End of transmission

Front 73

Come in (Radio Term)

Back 73

Requesting acknowledgement of transmission

Front 74

Copy (Radio Term)

Back 74

Message received and understood

Front 75

ETA (Radio Term)

Back 75

Estimated time of arrival

Front 76

Go Ahead (Radio Term)

Back 76

Proceed with your message

Front 77

Landline (Radio Term)

Back 77

Refers to telephone communications

Front 78

Over (Radio Term)

Back 78

End of message, awaiting reply

Front 79

Repeat/say again (Radio Term)

Back 79

Did not understand message

Front 80

Stand by (Radio Term)

Back 80

Please wait

Front 81

Break (Radio Term)

Back 81

Afford a "pause" so that the hospital can respond or interrupt if necessary.

Front 82

10-4 (Radio Term)

Back 82

Acknowledging that message is received and understood

Front 83

Clear (Radio Term)

Back 83

End of transmission

Front 84

Come in (Radio Term)

Back 84

Requesting acknowledgement of transmission

Front 85

Copy (Radio Term)

Back 85

Message received and understood

Front 86

ETA (Radio Term)

Back 86

Estimated time of arrival

Front 87

Go Ahead (Radio Term)

Back 87

Proceed with your message

Front 88

Landline (Radio Term)

Back 88

Refers to telephone communications

Front 89

Over (Radio Term)

Back 89

End of message, awaiting reply

Front 90

Repeat/say again (Radio Term)

Back 90

Did not understand message

Front 91

Stand by (Radio Term)

Back 91

Please wait

Front 92

Body Mechanics

Back 92

Safest and most efficient methods of using your body to gain a mechanical advantage, four simple principles:

Keep the weight of the object as close to the body as possible

To move a heavy object use the leg, hip, and gluteal muscles plus contracted abdominal muscles

Stack: visualize the shoulders stacked on top of the hips, and the hips stacked on top of the feet, then move them as a unit

Reduce the height or distance through which the object must be moved.

Front 93

Body Mechanics

Back 93

Safest and most efficient methods of using your body to gain a mechanical advantage, four simple principles:

Keep the weight of the object as close to the body as possible

To move a heavy object use the leg, hip, and gluteal muscles plus contracted abdominal muscles

Stack: visualize the shoulders stacked on top of the hips, and the hips stacked on top of the feet, then move them as a unit

Reduce the height or distance through which the object must be moved.

Front 94

Excessive lordosis

Back 94

The swayback. The stomach is too anterior and the buttocks are too posterior, causing excessive stress on the lumbar region of the back.

Front 95

Body Mechanics

Back 95

Safest and most efficient methods of using your body to gain a mechanical advantage, four simple principles:

Keep the weight of the object as close to the body as possible

To move a heavy object use the leg, hip, and gluteal muscles plus contracted abdominal muscles

Stack: visualize the shoulders stacked on top of the hips, and the hips stacked on top of the feet, then move them as a unit

Reduce the height or distance through which the object must be moved.

Front 96

Excessive lordosis

Back 96

The swayback. The stomach is too anterior and the buttocks are too posterior, causing excessive stress on the lumbar region of the back.

Front 97

Excessive kyphosis

Back 97

The slouch. In this posture the shoulders are rolled forward, which results in fatigue of the lower back and increases pressure on every region of the spine.

Front 98

Power lift

Back 98

Technique that offers you the best defense against injury and protects the patient with a safe and stable move.

Front 99

Power lift

Back 99

Technique that offers you the best defense against injury and protects the patient with a safe and stable move.

Front 100

Squat Lift

Back 100

An alternative technique you can use if you have one weak leg, one weak ankle, or if both your knees and legs are strong and healthy.

Front 101

Emergency Move

Back 101

Should be performed when there is immediate danger to the patient or to the rescuer

Fire or danger of fire, exposure to explosives, inability to protect the patient from other hazards at the scene

Inability to gain access to other patients who need life-saving care

Inability to provide lifesaving care because of the patient's location or position

Front 102

Emergency Move

Back 102

Should be performed when there is immediate danger to the patient or to the rescuer

Fire or danger of fire, exposure to explosives, inability to protect the patient from other hazards at the scene

Inability to gain access to other patients who need life-saving care

Inability to provide lifesaving care because of the patient's location or position

Front 103

Urgent Moves

Back 103

Patient is suffering an immediate life threat

Front 104

Emergency Move

Back 104

Should be performed when there is immediate danger to the patient or to the rescuer

Fire or danger of fire, exposure to explosives, inability to protect the patient from other hazards at the scene

Inability to gain access to other patients who need life-saving care

Inability to provide lifesaving care because of the patient's location or position

Front 105

Urgent Moves

Back 105

Patient is suffering an immediate life threat

Front 106

Rapid Extrication

Back 106

Urgent move, should be used in patients with any abnormality of the airway, breathing, oxygenation, or circulation and for those with critical injuries and illnesses.

Indicators:

Altered mental status

Inadequate respiratory rate

Indications of shock

Injuries to the head, neck, chest, abdomen, pelvis

Fracture of both femurs

Major bleeding

Front 107

Non-urgent moves

Back 107

No immediate life threat

Direct ground lift

Extremity lift

Direct carry method

Draw sheet method

Front 108

An unresponsive patient with no suspected head, neck, or spinal injury

Back 108

should be place in a left lateral recumbent position (coma or recovery position)

aids in draining and helps prevent aspiration into the lungs

Front 109

A patient with chest pain or discomfort or with breathing difficulties

Back 109

should be placed in a position of comfort, usually sitting up, if hypotension is not present

Front 110

A patient with suspected spinal injury

Back 110

should be immobilized on a long backboard

Front 111

A patient with suspected spinal injury

Back 111

should be immobilized on a long backboard

Front 112

A patient in shock

Back 112

should be placed in a supine position unless your protocol indicates otherwise

Front 113

An alert patient who is nauseated or vomiting

Back 113

should be transported in a sitting or a recovery position

allows you to manages the patient's airway

Front 114

An alert patient who is nauseated or vomiting

Back 114

should be transported in a sitting or a recovery position

allows you to manages the patient's airway

Front 115

a pregnant patient in her third trimester

Back 115

should be positioned on her left side

Front 116

Air Transport Packaging

Back 116

Contaminants removed

Airway properly managed

Leave chest accessible

Cover patient up