a poorly written patient care report: quizleet

What should the patient care report include?

The patient care report: A) provides for a continuum of patient care upon arrival at the hospital. B) is a legal document and should provide a brief description of the patient. C) should include the paramedic's subjective findings or personal thoughts.

Who should review a patient care report before submitting?

Prior to submitting a patient care report to the receiving hospital, it is MOST important for: A) your partner to review the report to ensure accuracy. B) the EMS medical director to review the report briefly. C) the paramedic who authored the report to review it carefully. D) the quality assurance team to review the report for accuracy.

How long do I have to complete a patient care report?

C) your patient care report must be completed within 36 hours after the call. 17. Prior to submitting a patient care report to the receiving hospital, it is MOST important for: A) your partner to review the report to ensure accuracy.

How accurate is my Patient Care report?

The accuracy of your patient care report depends on all of the following factors, EXCEPT: A) including all pertinent event times. B) the severity of the patient's condition. C) the thoroughness of the narrative section. D) documenting any extenuating circumstances.

What should you do if you make an error while writing your patient care report?

ERROR CORRECTION: Errors discovered while the report form is being hand-written should be corrected by drawing a single horizontal line through the error, initialing it, and writing the correct information beside it.

What are the components of a thorough patient refusal document?

Components of a thorough patient refusal document include: willingness of EMS to return to the scene if the patient changes his or her mind. When documenting a statement made by the patient or others at the scene, you should: place the exact statement in quotation marks in the narrative.

When a competent adult patient refuses medical care it is most important?

When a competent adult patient refuses medical care, it is MOST important for the paramedic to: ensure that the patient is well informed about the situation at hand.

Which of the following describes a pertinent negative?

A pertinent negative might be a​ patient's denial of pain after an automobile crash or a lack of difficulty in breathing in a case of chest pain. By noting the absence of pertinent signs and​ symptoms, you will provide the medical team that takes over care of the patient a fuller picture of his condition.

Why are patient care reports important?

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 are the 5 essential components of informed consent in the therapeutic setting?

In current clinical practice, these four elements translate into five components that should be included in a discussion seeking to obtain informed consent: the diagnosis, the proposed treatment, the attendant risks and benefits of the treatment, alternative treatments and their risks and benefits, and the risks and ...

What makes a patient incompetent?

An individual determined to be incompetent can no longer exercise the right to accept or refuse treatment. Competency is a legal term referring to individuals “having sufficient ability… possessing the requisite natural or legal qualifications” to engage in a given endeavor.

What are a few examples of when a patient can refuse treatment?

1 Accordingly, the patient may refuse to be informed about their medical condition and make a decision. An example would be the statement, “I don't want to hear anything from you. I'm not going to the hospital.” They may be informed and then refuse to make a decision. “Wow, that sounds bad either way.

What is it called when a patient refuses treatment?

Informed refusal is where a person has refused a recommended medical treatment based upon an understanding of the facts and implications of not following the treatment. Informed refusal is linked to the informed consent process, as a patient has a right to consent, but also may choose to refuse.

What is a pertinent negative and pertinent positive?

Pertinent positives, which are disease-specific and can be learned by rote, are used to “rule in” a particular diagnosis. Pertinent negatives, which require more analytical and creative thinking, are gleaned from the differential diagnosis and function to “rule out” other diagnostic possibilities.

What is a negative medical history?

An element of the patient's history that aids diagnosis because the patient denies that it is present.

What are the 4 examination levels?

Similar to the levels of history, there are four levels of physical exam documentation: Problem Focused. Expanded Problem Focused. Detailed. Comprehensive.

What Does A Patient Care Report Ensure?

In our hospital, a Patient Care Report (PCR) determines how patient care will be delivered in the future. The PCR process begins after your patient reaches the hospital. Blood pressure should have been recorded at 120/65 instead of 130/6 when attempting to document patient’s last blood pressure reading.

When You Complete The Patient Care Report You Should?

Fill in an abbreviated form with pertinent information about your patient, then complete the report at the appropriate time. use other colored ink to draw a single line on a patient care report once the error has been detected.

What Happens If There Are Documentation Errors In Healthcare?

It can lead to poor outcomes for patients and, by extension, the liability of the facility, the provider, and the nurse (because of errors made in documenting patients’ conditions, taking medications, and any other related matters.

Why Is It Important To Accurately Document In Your Patient Care Report?

In the first place, EMS documentation is essential for clinical practice. Your record of the health care you provide to patients is a vital piece of information.

Which Of The Following Best Explains Why All Patient Care Reports Done In The United States Are Supposed To Have The Minimum Data Set Included?

In the United States, every report pertaining to patient care involves at least one data set. Research and standardization are improved with this type of care.

Which Format Should Be Used When Writing The Narrative Section Of A Patient Care Report?

For more than a century, narrative documentation has primarily been recorded by SOAP methods. It contains all pertinent information. This acronym includes the information: Subjective: details about patient experiences such as time, symptom duration, history, etc., arising from a patient’s experiences with the illness or injury.

What Goes In A Patient Care Report?

In addition to identifying, describing and describing the event/incident, the condition of the patient, the care provided, and his/her medical history, the document can also contain but is not limited to information.