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17 Cards in this Set
- Front
- Back
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The written record of an EMS response.
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Prehospital care report (PCR)
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Uses for PCRs
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- Medical
- Administrative - Research - Legal |
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Time elapsed from when a unit is alerted until it arrives on the scene.
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Response time
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Scannable run sheet on which you fill in boxes or "bubbles" to record assessment and care information.
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Bubble sheet
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Characteristics of a Well-Written PCR
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- 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 |
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Elements of Good Documentation
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- Complete
- Accurate - Legible - Timely - Without alterations - Professional |
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Addition or supplement to the original report.
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Addendum
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Language used by a particular group or profession.
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Jargon
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Writing false and malicious words intended to damage a person's character.
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Libel
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Speaking false and malicious words intended to damage a person's character.
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Slander
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Approaches to the Physical Exam
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- Head-to-toe approach
- Body systems approach |
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What you believe to be your patient's problem, based on your history and physical exam.
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Field diagnosis
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Narrative Formats
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- SOAP
- CHART - Patient management - Call incident |
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SOAP
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- Subjective
- Objective - Assessment - Plan |
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CHART
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- Chief complaint
- History - Assessment - Rx (treatment) - Transport |
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Your patient refuses care even though you feel he needs it.
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Against medical advice (AMA)
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Tags containing vital information, affixed to your patient during a multiple-patient incident.
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Triage tags
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