15207740
Descripción
Fichas por Anthony Weckerling, actualizado hace más de 1 año
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Creado por Anthony Weckerling
hace más de 6 años
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| Pregunta | Respuesta |
| Prehospital Care Report (PCR) | factual record of events that occur during an EMS call or other patient contact |
| 3 Major Goals of PCR | 1. 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 |
| Uses for PCR | 1. 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 |
| Response Times | Time elapsed from when a unit is alerted until it arrives on scene |
| Bubble Sheets | computer-scannable reports on which to record patient info by filling in boxes or "bubbles" |
| Characteristics 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 |
| Elements of Good Documentation | - Complete - Accurate - Legible - Timely - Without Alterations - Professional |
| Addendum | additional/supplement to the original report |
| Jargon | language used by a particular group/profession |
| Libel | WRITING false/malicious words intended to damage a person's character |
| Slander | SPEAKING false/malicious words intended to damage a person's character |
| Subjective Narrative includes: | -Chief Complaint -History of Present Illness -Past History -Current health status |
| Objective Narrative includes: | -general impression -any data derived through inspection, palpation, auscultation, percussion, diagnostic testing |
| 2 Physical Exam Documentation Approaches | 1. Head-to-Toe approach 2. Body Systems approach |
| Head-to-Toe approach | - systematic and thorough approach - appropriate for major trauma and serious medical emergencies |
| Body Systems appraoach | - approach best suited to screening and pre-admission exams in which you conduct a comprehensive exam involving all body systems |
| Field Diagnosis | "impression" What you believe to be your patient's problem |
| Narrative Formats | - SOAP - CHART - Patient Management - Call Incident |
| SOAP 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 |
| CHART 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 |
| Patient Management format | chronological account from the time you arrived on scene until you transferred care to someone else |
| Call Incident format | Emphasizes the mechanism of injury, the surrounding circumstances, and how the incident occurred |
| 2 types of patients that might refuse care | 1. 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 |
| Against Medical Advise (AMA) | Patient refuses care even though you feel they need it |
| Benefits 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 |
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