Pearson - Paramedic Care: Principle And Practice Volume 1 Chapter 10

Front 1

The written record of an EMS response.

Back 1

Prehospital care report (PCR)

Front 2

Uses for PCRs

Back 2

- Medical
- Administrative
- Research
- Legal

Front 3

Time elapsed from when a unit is alerted until it arrives on the scene.

Back 3

Response time

Front 4

Scannable run sheet on which you fill in boxes or "bubbles" to record assessment and care information.

Back 4

Bubble sheet

Front 5

Characteristics of a Well-Written PCR

Back 5

- Appropriate medical terminology
- Correct abbreviations and acronyms
- Accurate, consistent times
- Thoroughly documented communications
- Pertinent negatives
- Relevant oral statements of witnesses, bystanders, and patient
- Complete identification of all additional resources and personnel

Front 6

Elements of Good Documentation

Back 6

- Complete
- Accurate
- Legible
- Timely
- Without alterations
- Professional

Front 7

Addition or supplement to the original report.

Back 7

Addendum

Front 8

Language used by a particular group or profession.

Back 8

Jargon

Front 9

Writing false and malicious words intended to damage a person's character.

Back 9

Libel

Front 10

Speaking false and malicious words intended to damage a person's character.

Back 10

Slander

Front 11

Approaches to the Physical Exam

Back 11

- Head-to-toe approach
- Body systems approach

Front 12

What you believe to be your patient's problem, based on your history and physical exam.

Back 12

Field diagnosis

Front 13

Narrative Formats

Back 13

- SOAP
- CHART
- Patient management
- Call incident

Front 14

SOAP

Back 14

- Subjective
- Objective
- Assessment
- Plan

Front 15

CHART

Back 15

- Chief complaint
- History
- Assessment
- Rx (treatment)
- Transport

Front 16

Your patient refuses care even though you feel he needs it.

Back 16

Against medical advice (AMA)

Front 17

Tags containing vital information, affixed to your patient during a multiple-patient incident.

Back 17

Triage tags

Front 18

Goals of the PCR

Back 18

1) To provide information to subsequent health care professionals about the patient and treatments provided in the prehospital setting.

2) To provide essential information for proper billing of the patient.

3) To provide a legal record of the call's circumstances.