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17 Cards in this Set
- Front
- Back
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Whenever possible record all times from?
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The same clock
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Document all findings of your assessment even?
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Those that are normal
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Certain findings in your PCR should never be left blank because?
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It gives the impression that you did'nt ask
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Elements of good documentation include?
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Completness
Accuracy Legibility Timeliness Absence of Alterations Professionalism |
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You should complete your report?
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Immediately after you completed the emergency call
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Addition or supplement to the original report?
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Addendum
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Approaches to the physical exam?
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Head to Toe and Body Systems
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What you believe to be your patient's problem, based on your history and physical exam?
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Field Diagnosis
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Record your complete management plan?
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From start to finish
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Four types of narrative formats?
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SOAP
CHART Patient Management Call Incident |
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SOAP stands for?
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Subjective
Objective Assessment Plan |
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CHART stands for?
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Chief Complaint
History Assessment Rx (treatment) Transport |
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AMA means
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against medical advice
(your patient refuses medical care even though you feel they need it) |
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Patients retain the right to refuse treatment or transport on what grounds?
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They are competent to make that decision
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The risks of denying transport are even greater then?
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Refusing transport
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Tags containing vital information, affixed to your patient during a multipatient incident?
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Triage Tags
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Poor, incomplete or inaccurate documentation encourages frivolous lawsuits while?
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Good documentation discourages them
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