if you make an error when completing a written patient care report, you should

Overall, you have to make your own judgment about which parts of your medical record need to be corrected if you find errors. If you are on the fence, it is better to correct something than to leave it incorrect. Contact the hospital or your payer to ask if they have a form they require for making amendments to your medical records.

Full Answer

When do you have to complete a patient care report?

B) pertinent details about the previous call may be omitted inadvertently. 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:

What should be included in the patient care report?

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. D) is only held for a period of 24 months, after which it legally can be destroyed.

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.

Should patients be allowed to criticize previous health care?

However, oral or written criticism of previous health care contributes nothing to the patient's needs. Patients may take casual remarks critical of prior care quite seriously, possibly destroying their relationships with previous caregivers and/or you.

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 4 principles of informed consent?

There are 4 components of informed consent including decision capacity, documentation of consent, disclosure, and competency.

What should a nurse do when a patient refuses treatment?

If your patient refuses treatment or medication, your first responsibility is to make sure that he's been informed about the possible consequences of his decision in terms he can understand. If he doesn't speak or understand English well, arrange for a translator.

Which of the following would be the most significant complication associated with incorrect use of medical terminology?

Which of the following would be the MOST significant complication associated with incorrect use of medical terminology? Ineffective treatment could be rendered.

What four areas decide if a patient's treatment decision is competent?

The four key components to address in a capacity evaluation include: 1) communicating a choice, 2) understanding, 3) appreciation, and 4) rationalization/reasoning.

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.

When evaluating a patient with multiple complaints the EMT's responsibility is to?

When evaluating a patient with multiple complaints, the EMT's responsibility is to: A. direct his or her attention to the most obvious signs and symptoms.

At what point in the patient assessment do you investigate the chief complaint?

At what point in the patient assessment process do you investigate the chief complaint? You investigate the chief complaint during history taking, as well as taking a SAMPLE history.

Why is it important to keep your medical records up to date?

Keep your records up-to-date in order to provide the best resource for patient care and evidence that appropriate and timely care was provided. Clinically pertinent information. The medical record is a primary mechanism for providing continuity and communication among all practitioners involved in a patient's care.

What should not be documented in Massachusetts?

What should not be documented. Derogatory or discriminatory remarks. In Massachusetts, patients have the right to access both office and institutional medical records and may be sensitive to notes they view as disrespectful or prejudicial. Include socio-economic information only if relevant to patient care.

What is current complete records?

Current, complete records which assist diagnosis and treatment, and which communicate pertinent information to other caregivers also provide excellent records for risk management purposes.

Can incomplete documentation impede patient care?

Missing, incomplete, or illegible documentation can seriously impede patient care and the defense of a malpractice claim, even when the care was appropriate. The following advice on documentation includes issues identified through analysis of malpractice claims. The most current information.

Can a patient's perceptions be inaccurately reported?

In addition, the patient's perceptions and recollections may be inaccurately reported. If, after complete information is considered, you do judge your patient's prior care to have been flawed, a factual summary of clinical events and honest answering of patient inquiries is advised.

Can you alter medical records?

Do not alter existing documentation or withhold elements of a medical record once a claim emerges. Periodically a physician defendant fails to heed this age-old advice. The plaintiff's attorney usually already has a copy of the records and the changes are immediately obvious.

Is incident report part of patient record?

Incident reports are not part of the patient record. Only clinically pertinent incident related information should be entered in the patient record. Put time and date on all entries in the medical record. Notes should be contemporaneous. Label added information as addendum and indicate when it was entered.