a patient care report reads:"pmh includes

A patient care report reads: "PMH includes ESRF and (+) DNR; (+) ASA pta of EMS." Regarding this description, which one of the following is true? Answer:

Full Answer

What should a prehospital care report read?

A prehospital care report​ reads: "GSW to​ LLQ." Based on​ this, you should recognize that the patient sustained​ a (n): Your partner states that he is the​ "world's worst​ speller" and has great difficulty using medical terms.

What happens after giving a prehospital care report to the nurse?

Immediately after giving a prehospital care report to the nurse in the emergency department, dispatch informs you that there are no more ambulances available and you must immediately leave the hospital to cover another portion of the county.

How do you determine the number of patients treated for hypercholesterolemia?

To best determine the number of patients treated for this​ condition, you​ would: review the previous prehospital care reports. When​ asked, an alert and oriented​ 44-year-old male tells you that he called 911 because​ "my chest is​ hurting." The man is also sweating and feels as if he is going to vomit.

What is included in a patient care report?

The primary purpose of the Patient Care Report (PCR) is to document all care and pertinent patient information as well as serving as a data collection tool. The documentation included on the PCR provides vital information, which is necessary for continued care at the hospital.

What would be considered an objective patient assessment findings?

Examples of objective assessment include observing a client's gait , physically feeling a lump on client's leg, listening to a client's heart, tapping on the body to elicit sounds, as well as collecting or reviewing laboratory and diagnostic tests such as blood tests, urine tests, X-ray etc.

Which format should be used when writing the narrative section of a patient care report?

SOAP NOTE: Traditionally, the SOAP method is used for narrative documentation and includes all pertinent information. SOAP is an acronym for a patient care report that includes: Subjective: details relative to the patient's experience of the illness or injury like onset time, history, complaint, etc.

What is the purpose of the narrative section of the patient care report?

Detailed explanation of medical necessity: Your narrative should be detailed and provide a clear explanation for why the patient needed to be transported by ambulance. Include what the medical reasons were that prevented the patient from being transported by any other means.

What are normal assessment findings?

Normal Findings No bone and cartilage deviation noted on palpation. No tenderness noted on palpation. Nasal septum in the midline and not perforated. The nasal mucosa is pinkish to red in color.

What is subjective and objective data?

Subjective data are information from the client's point of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews. Objective data are observable and measurable data (“signs”) obtained through observation, physical examination, and laboratory and diagnostic testing.

What is a component of the narrative section of a patient care report?

The narrative section of the PCR needs to include the following information: Time of events. Assessment findings. emergency medical care provided. changes in the patient after treatment.

How do you write a patient report?

III. Patient case presentationDescribe the case in a narrative form.Provide patient demographics (age, sex, height, weight, race, occupation).Avoid patient identifiers (date of birth, initials).Describe the patient's complaint.List the patient's present illness.List the patient's medical history.More items...•

What is a patient care form?

Patient care report or “PCR” means a report that documents the assessment and management of the patient by the emergency care provider.

What should be included in a narrative PCR?

Present the facts in clear, objective language. Include information like statements from the patient, a description of the surroundings, and medical observations. Make sure the narrative is structured in a logical order and include treatment and transport decisions.

When you document information on a patient that you treat and care for this written report is called the?

When you document information on a patient that you treat and care for. This written report is called the: Patient care report, run report. You are asked to give testimony in court about the care you gave to a patient.

What are the different components of a SOAP note?

The 4 headings of a SOAP note are Subjective, Objective, Assessment and Plan.

After a patient, who is short of breath, signs a refusal of service, which one of the following statements would be appropriate prior to leaving the residence? A) "Try taking an aspirin and get a good night's rest; you will probably feel better." B) "If you change your mind and want to be transported to the hospital, call 911." C) "We will leave this oxygen for you; call us when you feel better." D) "Call our dispatch in the morning to let us know how you made out."

B) "If you change your mind and want to be transported to the hospital, call 911.

Which one of the following statements shows an accurate understanding of the legal aspects of the prehospital care report (PCR)? A) "A PCR can be used in a lawsuit only if that lawsuit is filed within six months." B) "A copy of the PCR should be forwarded to the police any time law enforcement is involved in the call." C) "The PCR may be subpoenaed even if the case centers around alleged negligence that occurred in the emergency department." D) "The PCR is considered a legal document only when it describes a crime or act of violence."

C) "The PCR may be subpoenaed even if the case centers around alleged negligence that occurred in the emergency department."

Last week, on a computer generated report, you accidentally documented that a patient suffered from hypertension when, in fact, he did not. Unfortunately, the report has been locked by the computer and cannot be changed; however, it can be printed. Your first action would be to: A) retype the entire report and include the change. B) notify the medical director so that she can fix the error. C) print the report and draw a line through the error. D) contact the hospital and have them change it in the patient's medical record.

C) print the report and draw a line through the error.

A pertinent negative would be illustrated by: A) "nausea without vomiting." B) "hypertension and taking medication." C) "dizziness for three days without notifying the doctor." D) "short of breath with history of lung problems."

A) "nausea without vomiting."

Consider the following narrative from a patient care report: "pt. restrained passenger involved in 2 car MVC; c/o left lower leg pain rated 2/10; LOC A/O to person, place, time, and event; BBS clear; abd. Soft with tenderness LLQ; hx of NIDDM with am glucose level of 133 mg/dL." Which of the following is true? A) The patient's abdomen appears uninjured. B) The patient is being tested for diabetes. C) The patient is confused following the accident. D) The patient's lungs sounds are clear and equal.

D) The patient's lungs sounds are clear and equal.

A patient with asthma is using his inhaler tid and prn. You would recognize that: A) the patient is suffering asthmatic attacks three times a week. B) the patient is only prescribed his inhaler three times a day. C) the patient uses his inhaler only when the symptoms are bad. D) the patient uses an inhaler at least three times a day.

D) the patient uses an inhaler at least three times a day.

When writing a prehospital care report, you accidentally document that a laceration was on the left side of a patient's face when it was actually on the right side of the face. How would you correct this mistake? A) Carefully use White-Out to cover the term "left" but nothing else in the narrative. B) Color over the term "left" with black ink and write the word "right" next to it. C) Draw a single line through the term "left" and write the word "right" next to it. D) Start the entire prehospital care report over from the beginning.

C) Draw a single line through the term "left" and write the word "right" next to it.

Your partner states that he is the "world's worst speller" and has great difficulty using medical terms. Which one of the following statements is appropriate? A) "Do not document information that requires medical terms you are unsure of." B) "Consider abbreviating medical terms that you are unsure how to spell." C) "Ask the emergency physician or nurse how to spell the words of which you are unsure." D) "Use plain English if you are unsure of how to apply or spell a medical term."

D) "Use plain English if you are unsure of how to apply or spell a medical term."

A nauseated patient with fever and abdominal pain states that he has not vomited. Which one of the following describes how that fact should be documented? A) As a subjective finding B) This fact would not be documented. C) As a pertinent negative D) As a treatment finding

C) As a pertinent negative