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15 Cards in this Set
- Front
- Back
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PCR
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Prehospital care report
-the only truly factual record of events. -Documents exactly what you did, when you did it, and the effect of your interventions -Reflects your professionalism |
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Uses for PCR
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Medical: for HP staff
Administrative:quality improvment & system management Research improving pt care Legal:piece of evidence |
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Jargon
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language used by a particular group or profession
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Libel
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WRITING false and malicious words intened to damage a person's character .
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Slander
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SPEAKING false and malicious words intended to damage a person's character.
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Subjective Narrative
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What pt or bystander tell's you. (your told)
-includes cc, HPI, PH, CHS,ROS -in truma also includes MOI |
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Objective Narrative
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What you Find, your general impreesion
-Head-to-toe:entire physical exam -Body systems approach:Focuses on body systems |
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Field Diagnosis (or impression)
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what you believe to be your pt's problem based on your Hx and physical exam
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SOAP
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type of Narrative Format
Subjective Objective Assessment Plan |
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CHART
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Type of Narrative Formats
CC Hx Assessment Rx Transport |
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AMA
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Against Medical Advice
Pt refuses care even though you feel they need it. |
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Refuse Care Documentation Checklist
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Thorough Pt assessment
Competency of the Pt Your recommendation for care and transport Discuss those associated risk other suggestion for care willingness to return pt understanding |
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Triage tags
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Tags containing vital info, affixed to your pt during a MCI
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Good Documentation now enables good care later
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Poor incomplete, or inaccurate Documentation encourages frivolous laesuits; good documentation discourages them.
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record your complete management plan from start to finish
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document all your assessment, even those that are normal
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