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41 Cards in this Set
- Front
- Back
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What is the purpose of the Medical Documentation Guidelines? |
To promote excellence in documentation of pertinent patient care, provide needed information and statistics for quality assurance, and decrease the incidence of incurred liability and risk due to inadequate documentation. |
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In the delivery of pre-hospital emergency care, the weakest link in the care-giving phase is ______________ |
In the delivery of pre-hospital emergency care, the weakest link in the care-giving phase is not the actual interaction with the patient nor the provision of appropriate treatment methods, but the often overlooked and neglected area of documentation. |
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Documentation is the _______ phase of our pre-hospital care and treatment. |
Documentation is the final phase of our pre-hospital care and treatment. It is where our thoughts, investigation and patient care |
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The primary source for documentation will be the _____________ |
The primary source for documentation will be the E-PCR. |
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The primary responsibility for completion of the E-PCR will be the ___________ |
The primary responsibility for completion of the E-PCR will be the lead EMT/paramedic on the MFRU and the EMT/paramedic teching on Medic unit. |
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Assessment or treatment rendered by a MFRU prior to Medic unit arrival will be accomplished in the following manner: |
The Medical First Response Unit EMT or paramedic will provide information to the Medic unit on assessment and care rendered by utilizing the McVit card. |
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It is required that an E-PCR be completed by the MFRU EMT or paramedic any time a ________________ |
a medical procedure other than O2 or an IV is initiated. |
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The lead medic on the MFRU will be considered ___________ for purposes of documentation on their report. |
The lead medic on the MFRU will be considered Medic 1 for purposes of documentation on their report. |
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If the medic from the MFRU rides to the hospital, in the Medic Unit, he/she will be considered _______________ on the E-PCR. |
If the medic from the MFRU rides to the hospital, in the Medic Unit, he/she will be considered “Medic 1” on the E-PCR. |
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Each person transported to a medical facility for purposes of medical evaluation will have an E-PCR and ________________ completed. |
Each person transported to a medical facility for purposes of medical evaluation will have an E-PCR and Fire Report (24/7) completed. |
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Upon arrival at the incident, all persons must be offered a ________________ |
Upon arrival at the incident, all persons must be offered a medical assessment. |
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documentation purposes, it is essential that we deem a person a “_____________” or “___________.” |
"patient" or "no patient" |
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A “patient” is defined as any of the following: |
* Any person requesting or implying a medical evaluation. * Any person having a medical complaint or reasonable potential for injury. * A person experiencing a mental, behavioral, emotional, physical illness or injury. |
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Persons that are not transported for medical evaluation may fall under one of the following situations and require the following documentation. Cancelled en route |
Fire Apparatus: Fire Report Medic Unit: Fire Report |
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Persons that are not transported for medical evaluation may fall under one of the following situations and require the following documentation. No Patient |
Fire Apparatus: Fire Report Medic Unit: Fire Report |
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Persons that are not transported for medical evaluation may fall under one of the following situations and require the following documentation. Patient (if Transported) |
Fire Apparatus: Fire Report / EPCR Medic Unit: Fire Report / EPCR |
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Persons that are not transported for medical evaluation may fall under one of the following situations and require the following documentation. Patient not transported |
Fire Apparatus: Fire Report / Pt Release Medic Unit: Fire Report / Pt Release |
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Persons that are not transported for medical evaluation may fall under one of the following situations and require the following documentation. Dead on Arrival |
Fire Apparatus: Fire Report / EPCR Medic Unit: EPCR |
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Persons that are not transported for medical evaluation may fall under one of the following situations and require the following documentation. Assist Citizen |
Fire Apparatus: Fire Report Medic Unit: Fire Report |
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Persons that are not transported for medical evaluation may fall under one of the following situations and require the following documentation. MCI |
Fire Apparatus: Fire Report Medic Unit: EPCR |
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The Release of Liability report is designed to document what? |
The report is designed to document that every effort was made to inform the patient of assessment findings, risks, and advice to seek medical attention. |
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The paramedic or EMT shall read or allow the patient to read the report, ensure they understand it and always advise to seek medical attention should further questions or complications arise. true/false |
true
The paramedic or EMT shall read or allow the patient to read the report, ensure they understand it and always advise to seek medical attention should further questions or complications arise. |
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After obtaining the patient and witness’s signature, What should the patient or guardian be advised? |
After obtaining the patient and witness’s signature, the patient or guardian should be advised that they may obtain a copy of their record by contacting Fire Headquarters. |
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For incidents that do not require an E-PCR or Release Report, who is responsible for the Fire Report. |
For incidents that do not require an E-PCR or Release Report, the first arriving unit is responsible for the Fire Report. |
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For incidents where both a MFRU and a Medic Unit are on scene, the_________ is responsible for the Fire Report. |
For incidents where both a MFRU and a Medic Unit are on scene, the MFRU is responsible for the Fire Report. |
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MCI # of patients minumum |
Minimum of 6 patients to be considered
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MCI Complete the first report with the following information: |
* Case # * Call disposition (patient refusal or ED transport) * Incident location * Patient’s first and last name * Patient ___ of ___ * RPM in narrative section and chief complaint * Patient sign refusal * Then select “Add Patient” in disposition tab |
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what happens when you hit the "add patient" button? |
When you select “Add Patient”, it automatically downloads the time, incident location, and Case number into the next report. Complete the remaining patients’ information in the same manner. |
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What is the proper way to transfer care and submit patient care reports in the emergency setting? |
Upon arrival at the hospital a new E-PCR will be initiated by obtaining a medical record number, the signature of the patient, the receiving nurse and physician if applicable. A copy of the completed McVit card will be left with the receiving nurse. The Med Unit will go in service and finish the E-PCR at the station. Upon completion of the E-PCR a copy will be faxed or e-mailed to the ER no later than 6 hours |
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When a Med Unit becomes busy and gets backed up with _______ incomplete (refusal or transport) what should be done? |
If a Med Unit becomes busy and gets backed up with three (3) incomplete (refusal or transport) E-PCRs they shall notify the MS Officer who will arrange for coverage. |
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Documentation is a continuum of __________. |
patient care |
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Pertinent information concerning that patient must be recorded and kept as a part of _____________ |
Pertinent information concerning that patient must be recorded and kept as a part of the patient’s permanent medical record. |
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Failure to document (properly and correctly) has been construed by the courts as failure to treat and to monitor the patient, and may raise the presumption of ______________. |
Failure to document (properly and correctly) has been construed by the courts as failure to treat and to monitor the patient, and may raise the presumption of inadequate care. |
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C. Good documentation is a reflection of ______________ |
C. Good documentation is a reflection of good patient care. |
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D. If your report is not chronologically correct and appears confused, it may be construed that ________________, |
D. If your report is not chronologically correct and appears confused, it may be construed that YOU WERE CONFUSED, undermining your credibility as a medical professional. |
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Scheduled (controlled) pharmaceuticals will be maintained in the _____________. |
Scheduled (controlled) pharmaceuticals will be maintained in the Drug Box “B”. |
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Drug Box “B” will remain where, expect for under what conditions? |
Drug Box “B” will remain in the designated compartment of the vehicle at all times except during patient care. |
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how must scheduled (controlled) pharmaceuticals be discarded? |
care. Any scheduled (controlled) pharmaceutical that must be discarded in the whole or in part due to any reason, must be discarded in the presence of an EMT-I, Paramedic, RN or Physician and documented on the Controlled Substance Administration Record provided inside the drug box. |
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how must scheduled (controlled) pharmaceuticals be documented? |
inside the drug box. When documenting, record only one vial of medication per line of the controlled substance sheet. For example, if you were to administer 15 mg of Morphine, you would record 10 mg administered with no waste on the first line and on the second line 5 mg administered with 5 mg waste. Since Morphine is supplied in 10mg vials you would record 10 mg per line. |
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If for any reason there is a discrepancy during the narcotic check off, what should be done? |
If for any reason there is a discrepancy during the narcotic check off, immediately contact your Company Officer and Medical Supervisor. |
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If a narcotic is lost or broken, what should you do? |
contact your Company Officer and Medical Supervisor. If a narcotic is lost or broken, immediately contact your Company Officer and Medical Supervisor. A FD-2L will then need to be completed and forwarded through the chain of command to the Chief of Medical Operations. |
