consider the following narrative from a patient care report: "pt

What does a patient care report consist of?

A patient care report is a document made mostly by the EMS or EMTs. This documented report is done after getting the call. This consists of the information necessary for the assessment and evaluation of a patient’s care. What should not be written in a patient care report?

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 report a critically injured patient to the hospital?

You call the hospital to give report about your critically injured trauma patient. When you arrive, the staff is unprepared for your arrival and the physician is angry that you did not call and alert the hospital of your impending arrival.

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.

Which statement shows an accurate understanding of the legal aspects of the prehospital care report?

Which statement shows an accurate understanding of the legal aspects of the prehospital care report (PCR)? "The PCR may be subpoenaed even if the lawsuit centers on alleged negligence that occurred in the emergency department."

What would be considered an objective patient assessment finding?

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 one of the following describes an advantage of computerized documentation?

Which one of the following describes an advantage of computerized​ documentation? Large amounts of data can be stored and retrieved much easier than with the written PCR.

How do you write a patient care report for a narrative?

How to Write an Effective ePCR NarrativeBe concise but detailed. Be descriptive in explaining exactly what happened and include the decision-making process that led to the action. ... Present the facts in clear, objective language. ... Eliminate incorrect grammar and other avoidable mistakes. ... Be consistent and thorough.

What are the components of a narrative PCR 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 five steps of patient assessment?

emergency call; determining scene safety, taking BSI precautions, noting the mechanism of injury or patient's nature of illness, determining the number of patients, and deciding what, if any additional resources are needed including Advanced Life Support.

How do you write a patient assessment?

Assessment & PlanWrite an effective problem statement.Write out a detailed list of problems. From history, physical exam, vitals, labs, radiology, any studies or procedures done, microbiology write out a list of problems or impressions.Combine problems.

What are the 8 general principles for patient assessment?

Overview of Picker's Eight Principles of Patient Centered CareRespect for patients' values, preferences and expressed needs. ... Coordination and integration of care. ... Information and education. ... Physical comfort. ... Emotional support and alleviation of fear and anxiety. ... Involvement of family and friends. ... Continuity and transition.More items...•

What is the importance of medical report?

A medical report is a vital piece of evidence that can validate and support your claim for Social Security Disability benefits. Ideally, your medical report should be completed by a doctor or medical professional who is familiar with your condition and who has treated you for a significant period of time.

What are the four major categories of information in the health record?

Terms in this set (10)An ambulatory healthcare facility may be all of the following except. ... The four major categories of information in the health record include administrative, clinical, financial, and. ... Information standards include an official "Do Not Use" List of abbreviations.More items...

What are the types of patient records?

There are three types of medical records commonly used by patients and doctors:Personal health record (PHR)Electronic medical record (EMR)Electronic health record (EHR)

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

What Is a Patient Care Report?

We often hear of care reports based on by medical teams or by medical authorities. Yet, we are not sure how this differs from the kind of report that is given to us by the same people. So this is the time to make it as clear as possible.

How to Write a Patient Care Report?

Where do you even begin when you write a patient care report? A lot of EMS or EMTs do know how to write one since they are trained to do so.

What is a patient care report?

A patient care report is a document made mostly by the EMS or EMTs. This documented report is done after getting the call. This consists of the information necessary for the assessment and evaluation of a patient’s care.

What should not be written in a patient care report?

What should be avoided in a patient care report is making up the information that is not true to the patient. This is why you have to be very careful and very meticulous when writing these kinds of reports. Every detail counts.

Who is in charge of reading the patient care report?

The person or the people who will be reading the report are mostly medical authorities. When you are going to be passing this kind of report, make sure that you have all the information correctly. One wrong information can cause a lot of issues and problems.