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30 Cards in this Set
- Front
- Back
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Hgb:
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Hemoglobin
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Who can be held responsible if poor PCR results in inappropriate care?
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Medic who wrote doc
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Which words are spelled incorrectly?
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Thorax and Aspirin
(Both are proper names that should be capitalized:( ) |
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Potassium:
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K+
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Which allows you to increase amount of info you can quickly and efficiently write in PCR?
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Acronyms and abbreviations
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Absence of swollen ankles when ruling out CHF is a:
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Pertinent neg finding
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Which records provide the basis for continuous improvement of PT care in EMS?
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PCR
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PCR should document all the following except:
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Subjective opinion
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What is used to quickly record PT vital info in MCI?
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Triage tags
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Format that uses chronological account from the time of arrival on scene to the time of transfer of care is:
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PT management
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Which is proper medical term?
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Thorax
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PCRs for QI is example of --- use.
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Admin
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Narrative format that focuses on immediate management of a variety of PT problems:
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PT management
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PCR for research or QA you should block out:
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PT's ID info
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You can share info in PT chart to all but:
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Medics not on call
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What is PT's HR in narrative:
BLAH BLAH BLAH... |
Cannot be determined
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Abbreviation for acetaminophen:
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APAP
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All aspects of documentation apply to computerized EXCEPT:
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Subjective Medic comments
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To correct an error on PCR:
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Cross it out with one line and initial it
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Instead of "heart attack" medic could use the abbreviation:
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AMI
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Pertinent clinical info should be documented in the:
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Objective narrative
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When using direct PT statements, you should:
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Quote with quotation marks
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An accurate PCR includes all of the following EXCEPT:
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Medic opinion
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You are completing your PCR and cannot remember the correct spelling of medical term. You should:
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Use plain English instead
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How would you abbreviate "secondary to"?
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2*
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Abbreviation for nitroglycerin is:
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NTG
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Time between dispatch of unit and its arrival on scene?
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Response
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Only truly factual record of the events on an EMS call:
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PCR
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Call incident approach for narrative-writing emphasizes all of the following EXCEPT:
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Absolute chronological order
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Common pattern for organizing a narrative report is identified by the mnemonic:
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CHART
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