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26 Cards in this Set

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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