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161 Cards in this Set

  • Front
  • Back
Name the 4 uses for PCR's
Medical
Administrative
Research
Legal
QA/QI committees use PCR's to identify problems with __________________ paramenics or with the ________ _______________.
individual, EMS system
Define PCR
Prehospital Care Report; the written record of an EMS response
Your PCR reflects your __________________.
professionalism
Your PCR is an important document that helps ensure your patients ______________ ____ _________.
continuity of care
Define response time
Time elapsed from when a unit is alerted until it arrives on the scene
The __________________ _________________ (QA) or _________________ __________________ (QI) committee will use PCR's to identify problems with individual paramedics or the EMS system.
quality assurance, quality improvement
True or false: Your PCR provides the basis for continuously improving patient care in your EMS system.
True
A __________________, _______________, and ___________________ account of the emergency call may be your best and only defense in court.
complete, accurate, objective
True or false: You need to document your assessment of the patients condition only when arriving on scene and when arriving at the hospital.
False. A description of the pts condition upon arrival, during care, and when arriving at the hospital should be included. Condition before and after interventions should also be noted. All information should be objective.
What should be done if you do not know how to spell a word you are trying to use while writing your PCR?
You should look up the word, or use another word you know how to spell
_______________ or _________________ words reflect poorly on your professionalism.
Misspelled, misused
True or false: As long as you know what your abbreviations or acronyms stand for, that is all you need to be concerned with.
False. You must be familiar with approved abbreviations and acronyms for your local area.
Abbreviations
Abbreviations
Abdomen
Abd
Abdominal pain
abd pn
Head, eyes, ears, nose, and throat
HEENT
Obstetrical
OB
Respiratory
Resp
Chest pain
CP
Dyspnea on exertion
DOE
Fever of unknown origin
FUO
Gunshot wound
GSW
Headache
H/A
No apparent distress
NAD
Pain
pn
Shortness of breath
SOB
Abdominal aortic aneurysm
AAA
Acute myocardial infarction
AMI
Alcohol
ETOH
Chronic obstructive pulmonary disease
COPD
Congestive heart failure
CHF
Coronary artery bypass graft
CABG
CAD
Coronary artery disease
DVT
Deep vein thrombosis
Diabetes mellitus
DM
FBO
Foreign body obstruction
HBV
Hepatitis B virus
HTN
Hypertension
Inferior wall myocardial infarction
IWMI
IDDM
Insulin-dependent diabetes mellitus
ICP
Intracranial pressure
MCI
Mass casualty incident
MVC
Motor vehicle crash
NIDDM
Non-insulin-dependent diabetes mellitus
OD
Overdose
PID
Pelvic inflammatory disease
G/P
Pregnancies/Births (Gravida/Para)
PE
Pulmonary embolism
STD
Sexually transmitted disease
TIA
Transient ischemic attack
Tuberculosis
TB
URI
Upper respiratory infection
UTI
Urinary tract infection
WPW
Wolff-Parkinson-White syndrome
ASA
Aspirin
Bicarbonate
HCO-3
Birth control pills
BCP
Calcium
Ca++
Calcium chloride
CaCl2
Chloride
Cl-
Digoxin
Dig
Dilantin (phenytoin sodium)
DPH
Diphenhydramine
DPHM
Diptheria-Pertussis-Tetanus
DPT
HCTZ
Hydrochlorothiazide
Magnesium sulfate
Mg++
MS
Morphine sulfate
NTG
Notroglycerin
Nonsteroidal antiflammatory agent
NSAID
PCN
Penicillin
PB
Phenobarbital
K+
Potassium
NaHCO3
Sodium bicarbonate
Sodium chloride
NaCl
APAP
Tylenol
Anticubital
AC
LLL
Left lower lobe
LLQ
Left lower quadrant
Left upper lobe
LUL
Left upper quadrant
LUQ
Left ventricle
LV
RLL
Right lower lobe
RLQ
Right lower quadrant
Right middle lobe
RML
Right upper lobe
RUL
RUQ
Right upper quadrant
BBS
Bilateral breath sounds
CSF
Cerebral spinal fluid
Complete blood count
CBC
CT
Computerized tomography
Conscious, alert, oriented
CAO
EKG, ECG
Electrocardiogram
Electroencephalogram
EEG
Expiratory
Exp
FROM
Full range of motion
Full term normal delivery
FTND
HR
Heart rate
Insp
Inspiratory
JVD
Jugular vein distention
Laceration
lac
Level of consciousness
LOC
Moves all extremities
MAE
NT
Nontender
Palp
Palpation
P
Pulse
PEARL
Pupils equal and reactive to light
PERRLA
Pupils equal, round, reactive to light, and accomodation
R
Respirations
Unconscious
unc
UI
Urinary incontinence
ACLS
Advanced cardiac life support
ALS
Advanced life support
AMA
Against medical advice
Automatic external defibrillator
AED
Bag-valve mask
BVM
BLS
Basic life support
Cardiopulmonary resuscitation
CPR
CPAP
Continuous positive airway pressure
Do not resuscitate
DNR
ETT
Endotracheal tube
Estimated time of arrival
ETA
Intermittent positive-pressure ventilation
IPPV
LSB
Long spine board
NC
Nasal cannula
NG
Nasogastric
Nasopharyngeal airway
NPA
NPO
Nothing by mouth
Orophyngeal airway
OPA
O2
Oxygen
Short spine board
SSB
Rx
Therapy
Turned over to
TOT
Intracardiac
IC
IM
Intramuscular
IO
Intraosseous
Intravenous
IV
j
Joules
KVO/TKO
Keep vein open/To keep open
Orally
po
Subcutaneous
SC, SQ
Sublingual
SL
Whenever possible, times should be recorded using the same ___________.
clock or watch
When it is not possible to use the same watch or clok for recording times, watches should be ________________.
synchronized
True or false: If the same watch or clock is not used to record times, and they are not synchronized, it is okay just as long as you make the best guess.
False. If there is a difference in times, an explanation should be included in the narrative of your PCR.
Always document the ________________ __________, the orders you received, and the results of implementing that advice and those orders.
physicians name
Whenever possible, ____________ the pt or other sources directly. Indicate this by the use of ___________________ _____________.
quote, quotation marks
What are the 5 elements of good documentation?
Accuracy
Legibility
Timeliness
Absence of alterations
Professionalism
When should your PCR be completed?
Ideally, immediately after the call
Define addendum
Addition or supplement to the origional report
Define jargon
Language used by a particular group or profession
Define libel
Writing false and malicious words intended to damage a person's character
Define slander
Speaking false and malicious words intended to damage a person's character
What are the 2 approaches to the physical exam (2 types)?
Head-to-toe
Body systems
Define field diagnosis
What you believe to be your patients problem, based on your history and physical exam
What are the 4 narrative formats?
SOAP
CHART
Patient management
Call incident
What does SOAP stand for?
Subjective
Objective
Assessment
Plan
What does CHART stand for?
Chief complaint
History
Assessment
Rx (treatment)
Transport
The patient assessment format is a ____________________ account of the call.
chronological
The call incident approach emphasizes the __________________ ____ _____________, the surrounding circumstances, and how the incident occurred.
mechanism of injury
Define AMA
Against medical advice - your pt refuses care even though you feel he needs it