an accurate and legible patient care report

Your patient care report must be legible. This includes all signatures. If the person's signature is not legible, you can print their names and credentials below the signature line.

Full Answer

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.

Can a patient care report be revised after submission?

A) The original patient care report should be destroyed if a revision is necessary. B) Only the person who wrote the original report can revise or correct it. C) A patient care report cannot be revised or corrected after submission. D) If a report needs revision, the revision must be made within 12 hours.

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.

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.

What are the different criteria to use as guidelines in writing complete and accurate patient care report?

There are seven elements (at a minimum) that we have identified as essential components to documenting a well written and complete narrative.Dispatch & Response Summary. ... Scene Summary. ... HPI/Physical Exam. ... Interventions. ... Status Change. ... Safety Summary. ... Disposition.

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.

What are the functions of 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.

How would you correct a written error on a 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.

Which of the following most accurately defines negligence?

Which of the following MOST accurately defines negligence? Deviation from the standard of care that may result in further injury.

When providing patient care it is most important that you maintain effective communication with?

Emt E. When providing patient care, it is MOST important that you maintain effective communication with: your partner.

Why is patient report important?

'It is vital to collate and monitor how drugs affect patients to help improve the efficacy of medicines and reduce mishaps and harm from wrong dose levels or by identifying patient groups who are particularly vulnerable.

What should be included in a patient report?

A structured format incorporating elements of background information, medical history, physical examination, specimens obtained, treatment provided and opinion is suggested.

Why is it important for a health care provider to maintain accurate patient records?

Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time. At the end of the day, that's what really matters. Good documentation is important to protect you the provider. Good documentation can help you avoid liability and keep out of fraud and abuse trouble.

Why must the original content be legible when a correction is made in a patient's medical record?

Document the addition of the report and where it can be found. Why must the original content be legible when a correction is made in a patient's medical record? It shows no cover-up was intended.

How do you correct medical documentation?

If you want to have a mistake fixed, follow these steps:Step 1: Contact your provider. Contact your provider's office and find out what their process is for making a change to your health record. ... Step 2: Write down what you want fixed. ... Step 3: Make a copy of your request. ... Step 4: Send your request.

How do you correct documentation?

Make the correction in a way that preserves the original entry. Draw a single line through the erroneous entry and write the time, date, and your name. Identify the reason for the correction. Include the rationale in your notation; for example, “mistaken entry, wrong medication name written.”