Karteikarten
V1 C10 Documentation
Karten in diesem Stapel (25)
- 1Prehospital Care Report (PCR)factual record of events that occur during an EMS call or other patient contact
- 23 Major Goals of PCR1. To provide info to subsequent health care professionals about the patient/treatments provided in the prehospital setting
2. To provide essential info for proper billing of the patient
3. To provide legal record of the call's circumstances - 3Uses for PCR1. Medical - hospital staff may need more info from you
2. Administrative - EMS admin gather info for quality improvement & system management
3. Research - Analyze data
4. Legal - Permanent part of patient's medical record - 4Response TimesTime elapsed from when a unit is alerted until it arrives on scene
- 5Bubble Sheetscomputer-scannable reports on which to record patient info by filling in boxes or "bubbles"
- 6Characteristics of a well-written PCR- Appropriate Medical Terminology
- Correct Abbreviations/Acronyms
- Accurate, Consistent times
- Thoroughly documented comms
- Pertinent negatives
- Relevant oral statements (witnesses, bystanders, patient)
- Complete ID of all additional resources & personnel - 7Elements of Good Documentation- Complete
- Accurate
- Legible
- Timely
- Without Alterations
- Professional - 8Addendumadditional/supplement to the original report
- 9Jargonlanguage used by a particular group/profession
- 10LibelWRITING false/malicious words intended to damage a person's character
- 11SlanderSPEAKING false/malicious words intended to damage a person's character
- 12Subjective Narrative includes:-Chief Complaint
-History of Present Illness
-Past History
-Current health status - 13Objective Narrative includes:-general impression
-any data derived through inspection, palpation, auscultation, percussion, diagnostic testing - 142 Physical Exam Documentation Approaches1. Head-to-Toe approach
2. Body Systems approach - 15Head-to-Toe approach- systematic and thorough approach
- appropriate for major trauma and serious medical emergencies - 16Body Systems appraoach- approach best suited to screening and pre-admission exams in which you conduct a comprehensive exam involving all body systems
- 17Field Diagnosis"impression"
What you believe to be your patient's problem - 18Narrative Formats- SOAP
- CHART
- Patient Management
- Call Incident - 19SOAP Format- SUBJECTIVE - chief complaint, history of present illness, past history, current health status, family history, psychosocial history, review of systems
- OBJECTIVE - Vital signs, general impression, physical exam, diagnostic tests
- ASSESSMENT - Field diagnosis
- PLAN - standing orders, physician orders, effects of intervention, mode of transportation, ongoing assessment - 20CHART Format- CHIEF COMPLAINT - primary problem/complaint
- HISTORY - history of present illness, past history, current health status, review of systems
- ASSESSMENT - vital signs, general impression, physical exam, diagnostic tests, field diagnosis
- Rx - standing orders, physician orders
- TRANSPORT - effects of intervention, mode of transportation, ongoing assessment - 21Patient Management formatchronological account from the time you arrived on scene until you transferred care to someone else
- 22Call Incident formatEmphasizes the mechanism of injury, the surrounding circumstances, and how the incident occurred
- 232 types of patients that might refuse care1. Person who is not seriously ill/injured and simply does not want to go to hospital
2. Patient that refuses care even though you feel he/she needs it - 24Against Medical Advise (AMA)Patient refuses care even though you feel they need it
- 25Benefits of Electronic PCR (ePCR)-greater ease of data collection/analysis
-consistent, uniform, easy to read patient chart
-reduction of poor penmanship/spelling errors
-opportunity for an EMS administrator to configure/alter the software
-integrate with dispatch software, billing services, and regulatory agencies
-interface with medical devices
-better quality assurance processes, chart reviews, and feedback to EMT/paramedic