Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
26 Cards in this Set
- Front
- Back
|
The sole permanent, complete written record of events during an ambualnce call, considered the most comprehensive and reliable record of the event, and it reflects your professionalism is called ?
|
PCR
(Patient Care Report) (p 736) |
|
|
Name the 4 uses of your PCR
|
1-Medical
2-Administrative 3-Research 4-Legal (P736) |
|
|
What becomes a permanent part of your PT's medical record?
|
PCR
(p 737) |
|
|
Never write _____ ______ in your PCR's
ex. "the pt is drunk, obnoxious, and looks like a crack addict" |
Subjective Opinions
(p 738) |
|
|
*Appropriat medical terminology
*correct abbreviations/acronyms *accurate, consistent times *thoroughly documented communications * pertinent negatives * relevant oral statements of witnesses * complete ID's of all ADDT'L resources and personnel All are ? |
Characteristics of a Well-Written PCR
(p738) |
|
|
Name a major problem with using Medical abbreviations/acronyms?
|
Medical abbreviations/acronyms sometimes have multiple meanings
(P 738) |
|
|
The times recorded on the PCR are considered?
|
The OFFICIAL times of the incident (743)
|
|
|
A common problem with documenting times is the?
|
Inconsistencies of the dispatch center clock, ambulance clock, and your watch
(P 743) |
|
|
An essiential component of good documentation is the appropriate use of _____ _______.
|
Medical terminology/terms
(p 738) |
|
|
The risks of denying transport are even greater then?
|
Refusing transport
|
|
|
Whenever possible record all times from?
|
The same clock
|
|
|
Document all findings of your assessment even?
|
Those that are normal
|
|
|
Certain findings in your PCR should never be left blank because?
|
It gives the impression that you did'nt ask
|
|
|
Elements of good documentation include?
|
Completness
Accuracy Legibility Timeliness Absence of Alterations Professionalism |
|
|
You should complete your report?
|
Immediately after you completed the emergency call
|
|
|
Addition or supplement to the original report?
|
Addendum
|
|
|
Approaches to the physical exam?
|
Head to Toe and Body Systems
|
|
|
What you believe to be your patient's problem, based on your history and physical exam?
|
Field Diagnosis
|
|
|
Record your complete management plan?
|
From start to finish
|
|
|
Four types of narrative formats?
|
SOAP
CHART Patient Management Call Incident |
|
|
SOAP stands for?
|
Subjective
Objective Assessment Plan |
|
|
CHART stands for?
|
Chief Complaint
History Assessment Rx (treatment) Transport |
|
|
AMA means
|
against medical advice
(your patient refuses medical care even though you feel they need it) |
|
|
Patients retain the right to refuse treatment or transport on what grounds?
|
They are competent to make that decision
|
|
|
Tags containing vital information, affixed to your patient during a multipatient incident?
|
Triage Tags
|
|
|
Poor, incomplete or inaccurate documentation encourages frivolous lawsuits while?
|
Good documentation discourages them
|
