f an action or procedure that was performed on a patient is not recorded on the written report:

by Prof. Lavern Brakus DVM 3 min read

Chapter 3 Emt Flashcards - Quizlet

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If an action or procedure that was performed on a patient is not recorded on the written report: it was not performed in the eyes of the law. it can be qualified by the EMT in charge. it cannot be used in establishing negligence.

What if a procedure is not documented in a medical record?

From a legal standpoint a procedure not documented was not performed Why should the following be charted in a patients medical record: *Specimens collected from a patient The physician would know that the specimen was collected and sent out to the lab if results were not back yet

Why is a report sent to the patient's family physician?

To provide information to the patient's (family) physician for the continuity of future care and to respond to authorized requests for information regarding a patient's hospitalization Why is a copy of the emergency room report sent to the patient's family physician? For the purpose of providing follow-up care

What chapter in the medical record is evaluation of learning?

Chapter 38: The Medical Record - Evaluation of Learning STUDY Flashcards Learn Write Spell Test PLAY Match Gravity Created by cassandra_nagy Terms in this set (50)

What are the general guidelines for documenting in a patient's medical record?

List the general guidelines for documenting in a patient's medical record. 1) Check the name and DOB on the EMR or paper chart before making an entry to ensure you have the correct record 2) Document information accurately in logical order, using clear and concise phrases 3) Spell correctly

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.

Which of the following components are needed to prove negligence EMT?

In order to establish negligence, you must be able to prove four โ€œelementsโ€: a duty, a breach of that duty, causation and damages.

Is the manner in which the EMT must act when treating patients?

The manner in which the EMT must act or behave when caring for a patient is called the: standard of care.

Which of the following patients has the legal right to refuse treatment?

Every competent adult has the right to refuse unwanted medical treatment. This is part of the right of every individual to choose what will be done to their own body, and it applies even when refusing treatment means that the person may die.

Which of the following must be present for an action to be considered negligence?

Negligence claims must prove four things in court: duty, breach, causation, and damages/harm. Generally speaking, when someone acts in a careless way and causes an injury to another person, under the legal principle of "negligence" the careless person will be legally liable for any resulting harm.

Which of the following is not essential in determining if an action is due to negligence?

Which of the following is not essential in determining if an action is due to negligence? The injured party must prove the wrongdoer committed a criminal act - Negligence is the commission of a civil or private wrong, not a criminal wrong.

When performing his or her duties the EMT is expected to?

When performing his or her duties, the EMT is generally expected to: exercise reasonable care and act prudently. In which of the following situations does a legal duty to act clearly exist? A call is received 15 minutes prior to shift change.

What is the primary ethical consideration for the EMT?

Within the scope of practice of an EMT, the primary ethical consideration is to make patient care and well-being a priority, even if this requires some personal sacrifices. ________ 2. Consent, or permission from the patient, is required for any treatment or action by the EMT.

In which of the following situations should an EMT withhold resuscitative measures?

In which of the following situations should an EMT withhold resuscitative measures from a patient in cardiac arrest? The patient's caregiver presents a DNR order signed by the patient and his physician.

How do you document patient refusal?

DOCUMENTING INFORMED REFUSALdescribe the intervention offered;identify the reasons the intervention was offered;identify the potential benefits and risks of the intervention;note that the patient has been told of the risks โ€” including possible jeopardy to life or health โ€” in not accepting the intervention;More items...

What criteria must a patient meet in order to legally be allowed to refuse care?

3) In order for a patient to refuse treatment and/or transportation two events must occur to protect both the patient and yourself: 1) You must give the patient enough information about the decision Page 2 2 they are making so that there is an informed consent, and; 2) You must be satisfied that the patient has ...

Under what circumstances does a health care professional have the right to refuse treatment to a patient?

When Can Doctors Refuse to Treat? According to Stat News, physicians can ethically refuse to treat patients who are abusive, when such treatment falls outside their scope of practice, and when a patient's care comes into conflict with the physician's duties.

What does it mean when a patient tells you he changed his mind?

The correct answer is: A. decomposition of the body's tissues. Shortly after loading your patient, a 50-year-old man with abdominal pain, into the ambulance, he tells you that he changed his mind and does not want to go to the hospital. He is conscious and alert and has no signs of mental incapacitation.

What does it mean when a patient regains consciousness?

The patient tells you that he feels fine and does not want to go to the hospital. Under these circumstances, you should:

What is the meaning of "documents the results of treatments and patient's progress"?

Tap card to see definition ๐Ÿ‘†. 1) Documents the results of treatments and patient's progress. 2) Basis for decisions regarding the patient's care and treatment. 3) Efficient and effective method by which information can be communicated between authorized personnel. Click again to see term ๐Ÿ‘†.

How to document a patient's medical record?

1) Check the name and DOB on the EMR or paper chart before making an entry to ensure you have the correct record. 2) Document information accurately in logical order, using clear and concise phrases. 3) Spell correctly.

What are some examples of HIPAA not required consent?

List examples of when HIPAA does not require written consent for the use of disclosure of a patient's health information in the following categorizes: 1) Treatment: 2) Payment: 3) Health care operations: 1) Treatment: a. Patient referral to specialist. b. Emergency care provided at a hospital.

What are the instructions given to the patient regarding medical care?

5) Instructions given to the patient regarding medical care. 1) Allergies and current medications. a. To let the physician know of any changes in the medications that the patient is actually taking. 2) Procedures performed on the patient. a.

What are some examples of medical history?

List five examples of information included in the past medical history. 1) Allergies. 2) Current medications. 3) Immunizations.

What are the functions of a medical record?

List three functions of the medical record. 1) Documents the results of treatments and patient's progress. 2) Basis for decisions regarding the patient's care and treatment. 3) Efficient and effective method by which information can be communicated between authorized personnel.

What are the uses of health history?

1) To determine the patient's general health. 2) To arrive at a diagnosis and to prescribe treatment. 3) To document any changes in a patient's illness after treatment has been instituted.