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27 Cards in this Set
- Front
- Back
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What do you call the record that you produce during the call?
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Prehospital Care Report (PCR). Some services call it a trip sheet, run report, or other names.
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What's a Prehospital Care Report (PCR)?
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It's the patient record that you produce during a call.
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What's one major difference between a computerized report and a written report?
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A written report contains narrative space where you can write things in your own words -- computerized reports consist of just boxes you shade in so computers can scan them.
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What are main purposes of the prehospital care report?
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It serves as a record of patient care, as a legal document, provides information for administrative functions, aids education and research, and contributes to quality improvement.
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What happens to a PCR after it's filled out?
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It becomes part of the patient's permanent hospital record.
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What does a PCR allow hospital staff to do?
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It allows hospital staff to look back at original sets of vitals and observations in order to better treat the patient.
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In what cases does a PCR become a legal document?
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In cases where the patient was the perp or victim in a crime, or during civil law proceedings. Also, it can be examined if and when you become the subject of a lawsuit.
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What administrative purposes does a PCR serve?
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It assists you in obtaining insurance and billing information from a patient or the patient's family.
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Define "data element."
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Each individual box in a prehospital care report is a data element.
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Define "minimum data set."
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This is a guideline issued by the US DOT that recommends the minimum elements to be included in all PCR's nationwide.
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Name some sections of the prehospital care report
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Run data, patient data, check boxes, narrative section
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What is "run data?"
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This includes the agency name, unit number, date, times, run or call number, crew members' names, licensure levels, and numbers. Remember -- the times that you record must match the dispatcher's times.
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Name some elements of the minimum data set.
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Patient information (recorded at initial contact, following interventions, and upon arrival at medical facility):
Chief complaint Mental status Blood pressure Capillary refill (for children under 6) Skin color and temperature Pulse rate Respiratory rate and effort Administrative information: Time of incident report Time unit notified Time of arrival at patient Time unit left scene Time of arrival at destination Time of transfer of care |
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Name some elements that make up "patient data."
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Patient's name, address, DOB, age, sex
Billing and insurance information Nature of the call Mechanism of injury Location patient was found Treatment administered before arrival of EMT Signs and symptoms, vitals SAMPLE history Care administered and the patient's response to said care Changes in condition throughout call |
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Define "narrative" as it pertains to a PCR.
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This is where an EMT "paints a picture" of the patient. This should tell the patient's story fully. It should be complete, accurate, and should contain both pertinent subjective AND objective information.
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In the narrative section of a PCR, If you record something that you didn't observe yourself (observations of bystanders), what do you do?
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Put those statements in quotes so that the reader knows where the information came from.
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What is a "pertinent negative?"
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It's a piece of information that you should record. It's a finding that's negative but important to note... for example, if a patient denies pain in the left arm even though they're injured there, or they deny difficulty breathing though their respiratory rate is through the roof, you should record that.
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What should you avoid on all written reports?
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Radio codes and nonstandard abbreviations. Also, opinions. Just write the facts.
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If it's not written down...
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...you didn't do it.
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List some important steps to take and information to include when documenting a patient refusal.
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1) Try again to persuade the patient to go to a hospital
2) Ensure that the patient is able to make a rational, informed decision 3) Inform the patient why they must go, and of the consequences of refusing care 4) Consult medical direction 5) If the patient still refuses, document any assessment findings and emergency medical care given, then have them sign a refusal form 6) Have a family member, police officer, or bystander sign the form as a witness. If the patient refuses to sign, have a witness provide evidence that the patient refused to sign. |
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Describe some possible consequences of falsifying information on a prehospital care report
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Poor patient care, suspension or revocation of your EMT license
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Describe how to properly correct an error in a prehospital care report.
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Draw a single line through the error, initial it, and write the correct information beside it.
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What two types of errors might be committed during a call?
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omission and commission. Omission is missing or forgetting a necessary intervention or assessment.
Commission is an action performed on the patient that was incorrect or improper, such as administering the wrong medication or dosage. Document all errors! |
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What's a triage tag?
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This is a small document affixed to the patient and used to record chief complaint and injuries, vitals, treatments given, etc.
This is usually used in MCIs when it's tough to conduct thorough documentation and it's essential that this information travels with the patient. |
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What's a special situation report?
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This is a supplemental report used in certain situations, such as calls when ALS is required, or very complex or involved calls.
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What are some other cases in which supplemental reporting may be necessary?
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Exposure to infectious disease
Injury to yourself or another EMT Hazardous or unsafe scenes Referrals to social services for case of abuse, etc. |
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What does CHART stand for?
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Chief complaint
History Assessment Rx (treatment) Transport ...this is an alternate method of record-taking |
