a poorly written patient care report quizlet

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.

When do you need to document a patient who refuses care?

D) Documentation is required only if you feel the patient refused care inappropriately. Comprehensive documentation might have to be postponed until all patients are triaged and transported. How should a paramedic document the events during a major incident involving several patients?

Who completes the documentation for each patient?

A) Documentation for each patient should be completed by the Incident Commander.

Do you need to document an EMS response?

C) There is no need to document the EMS response.

What is the purpose of sharing information with EMS providers about patient outcome?

share information with the EMS providers about patient outcome for purposes of quality assurance and education.

Should a caller's name be complete?

should be complete to the point where anyone who reads it understands exactly what transpired on the call.

Can patient information be shared?

patient information shall not be shared with entities or persons not involved in the care of the patient.

What is the purpose of sharing information with the EMS providers about patient outcomes?

share information with the EMS providers about patient outcomes for purposes of quality assurance and education

Who can revise a report?

only the person who wrote the original report can revise or correct it

Should a caller's name be complete?

should be complete to the point where anyone who reads it understands exactly what transpired on the call

Can patient information be shared?

patient information shall not be shared with entities or persons not involved in the care of the patient.

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 Is A Patient Report?

An itemized patient report provides information about both the patient’s healthcare record and personal matters. Most health care providers write these forms at the request of doctors when they perform a medical consultation. The request may also be made if the entity needs it on behalf of its administration.

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

Your record of the health care you provide to patients is a vital piece of information. In addition to recording the care the patient receives on-site, an accurate patient record may also be crucial in the patient’s treatment at an ED, trauma center, or other facility receiving patients.

Who Should Correct An Error In A Patient’s Chart?

Your practice may have a practice policy concerning medical records amendment. Whenever a physician identifies an error, a staff member is responsible for pointing out the issue to him or her. Never correct an error. Keeping your medical records is a legal requirement depending on where you live.

What is a C billing system?

C) is a nationwide billing system that any EMS provider can use.

Do insurance companies pay if unapproved abbreviations are used?

D) insurance companies do not pay if unapproved abbreviations are used .