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49 Cards in this Set

  • Front
  • Back
Functions of a PCR
-continuity of medical care
-admin uses
-legal document
-educational and research uses
-evaluation and continuous quality improvement
PCR
documentation of an emts contact with a patient
Does the documentation you provide become part of the patients permanent hospital record?
YES
continuity of medical care
-provides a baseline for other providers
-gives an understanding of events and reasons for call
PCR legal
-is a legal document
-may be called as a witness
-documentation can be an essential part to your defense
PCR formats
-written-most traditional format, combines check boxes and write on lines for vitals along with other areas for writing a fuller narrative
-computerized- a.)some have boxed sheets that are then scanned in computer
b.) on others data is directly entered into a PDA or laptop.
Can the emts computer be linked to diagnostic equipment, to electronic medical records, to CAD, systems handling fleet management, etc?
yes
2 basic rules for PCR
if it wasnt written down it didnt happen

if it wasnt done dont write it down
why does DOT make an effort to standardize care?
such general standardization will hopefully lead to a higher level of patient care across nation
minimum data set
patient info- cheif complaint, loc, bp, skin perfusion, skin color, temperature and condition, pulse rate, resp rate and effort, patient deomgraphics.

admin info-time incident reported, time unit was notified, time of arrival at patient, time the unit left the scene, time unit arrive at destination (hospital) time of transfer of care
How many sets of vital signs shall be taken and recorded?
ideally atleast two complete sets of vitals should be taken and recorded, also important to note the patients position when taking the vitals. Also critical to record the time which vitals taken.
PCR narrative section
-brief but thorough picture of the patient for other medical personnel to use
-chief complaint, sample, objective data, subjective data, and pertinent negatives.
treatment section of pcr
chronological order of treatments given, the time they were administered and the patients response to treatment
refusal of treatment highlights
-inform patient of why they should go to hospital and consequences of not going
-always make an effort to persuade patient to go before leaving
-discuss situation with medical control, doctor may convince patient or give guidelines for emt for a refusal
-document assesment findings you have done also document patient is alert and a&o x 4
-explain that you can always come back
false information may lead to?
suspension, or revocation of emt certification or license, and may lead to criminal charges
transfer of care report
-
-obtain signature from medical professional who is assuming care (if able to)
-leave a copy of report at facility
-a cope of transfer of care report shall be submitted with full pcr
mci patients and documentation
the needs of patients conflict with the needs of complete documentation
-often just a triage tag used for pcr later
special report sitautions
abuse of child or elderly
-possible exposure to disease
-injury to ems member
-other sits where emt deems neccessary
SOAP
alternative method for documentation
S-subjective
O-objective
A-assessment
P-plan
CHART
C-chief complaint
H-history
A-asessment
R-rx
T-transport
CHEATED
C-chief complaint
H-history
E-exam
A-assessment
T-treatment
E-evaluated
D-disposition
Best way to move a patient?
the easiest way that will not cause injury or pain to your patient or yourself
Body mechanics
safest and most efficient methods of using your body to gain a mechanical advantage
4 basic principles
-keep weight of object as close to body as possible
-to move a heavy object use legs, hip, and buttocks muscles plus contracted abdominal muscles
-stack-visulaize shoulders tacked on top of hips, hips stacked on top of feet, move them as unit
-reduce height or distance object must be moved
lordosis
stomach is too anterior and buttocks to posterior
kyphosis
the shoulders are rolled forward, which results of fatigue of lower back and increases pressure on every region of spine
general guidelines for lifting and moving
always try to use an even number of rescuers
-two rescuers should carry a heavy load for 1 minute or less
-never lift and twist simultaneously
powerlift
feet are apart,knees bent, back and abdominal muscles tightened, back as straight as possible, lifting force driven through heels and arches
-a useful technique for rescuers with weak knees and thighs
powergrip
recommended gripping technique, the alms and fingers come in complete contact with the object and all fingers are bent at same angle
squat lift
use if you have one weak leg or ankle, or both knees and legs are strong and healthy
-place weaker leg slightly forward, and push yourself upper with your stronger leg
one handed carry
keep your back locked, and avoid leaning to opposite side too much
when it is necessary to reach how far should reach for something?
15 to 20 inches, no more than 20
pushing
whenever possible push rather than pull, keep push area between waist and shoulders
pulling
avoid when possible, keep load between shoulders and hips
emergency move
immediate danger to patient or rescuer (fire, expolsives, hazmat, inability to protect patient from hazards at scene, inability to gain access to patients who need care, inability to provide lifesaving care because of the patients location or position.
types-shirt drag, blanket drag, armpit forearm drag
urgent moves
patient is suffering immediate threat to life
type rapid extrication (loc, inadequate resp, indications of shock, major bleeding, fracture of both femurs
nonurgent moves
no immediate threat to life, choose best equipment and positioning for moving patient safely.
-direct ground lift, extremity lift, direct carry method, draw sheet method
wheeled stretcher
-device most commonly used
-rescuer at head pushes and rescuer at feet guides
-two types lift in and roll in, roll in type has specialized wheel at head to simplify loading, it significantly reduces amount of twisting and lifting required
-never leave patient unattended
disadvantage-difficult to maneuver on uneven terrain
bariatric stretcher
up to 1600 lbs
-larger wheels, wider cot, heavily constructed frames
portable stretcher
-particularly useful when the patient must be removed from a confined or too narrow space that wheeled stretcher won fit into.
-should not be used when spinal immobilization is needed unless used with a long backboard
-care must be taken when putting patient on rock ground
-three types-basic model, the breakaway, basic with folding wheels and posts
-
stair chair
-usefull when a wheeled stretcher cannott navigate down narrow corridors and doorways, small elevators, and stairways.
-dont use for altered loc, suspected spinal injury, or injury to lower extremities
backboards
-protects patient from rocky ground and acts as spinal immobilizer
-if use a short backboard such as a ked then put them on a long backboard after (short backboards good for immobilize patients that are sitting)
scoop stretcher
-up to 300 lbs, made to be assembled and disassembled around patient, used in confined areas where other conventional stretchers will not fit.
-also good of for pelvic or bilateral femural fractures
-2 or more rescuers required
-note for spinal injuries
basket strecther
-commonly called stokes basket
-will accommodate a scooped stretcher or ohio backboard
-allows you to completely immobilize a patient who is already in backboard for rough terrain
flexible stretcher
-special transfer device made of canvas or synthetic materials
-especially usefull for narrow and restricted hallways found in mobile homes
position put pregnant women in?
-on left side to prevent supine hypotensive
-if there is excess vaginal bleeding place in supine position, if suspect prolapsed cord place woman on back and elevate hips
unresponsive patient with no head, neck or, spinal trauma
put in left lateral recumbent
patient with chest pain or breathing difficulties
placed in postion of comfort usually sitting up
alert patient who is nauseated placed?
in sitting or recovery position