in which of the following circumstances is a fully documented patient care report not necessary?

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.

What information should be entered in 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.

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.

Is the plan of care an effective form of documentation?

Among the more specialized types of documentation is the plan of care, a requirement of the Joint Commission.1, 2Though planning and plans should facilitate information flow across clinician providers there is little generalizable evidence about their effectiveness.

Which of the following is not an appropriate way of dealing with a patient who does not speak the same language as you do?

Which of the following is NOT an appropriate way of dealing with a patient who does not speak the same language as you do? Avoid communicating with the patient so there is no misunderstanding of your intentions.

Which of the following is the most important reason for maintaining good documentation standards?

Which of the following is the MOST important reason for maintaining good documentation​ standards? Good documentation contributes to continuity of care.

What is the most important part of a patient care report?

What is the most important section of the Patient Care Report and what does it include ? The narrative section is the most important part ; it includes what you saw at the scene, what treatment you provided, how did the patients condition change.

What does the patient care report ensure?

The patient care report (PCR) ensures: Continuity of care. After delivering your patient to the hospital, you sit down to complete the PCR.

Why are patient records necessary?

The maintenance of good medical records ensures that a patient's assessed needs are met comprehensively. Information in medical records should be documented on a daily basis and in chronological order demonstrating continuity of care and response to treatment.

What are reasons for documentation?

Your documentation is no longer a side project, instead, here's 7 reasons why documentation is foundational for your success:1) Reduced Time Waste. Consistency equals efficiency. ... 2) Fewer Errors. ... 3) Superior Customer Service. ... 4) Lower Training Costs. ... 5) Competitive Advantage. ... 6) Greater Accessibility. ... 7) Trusted Security.

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.

What is pertinent negative?

Pertinent Negatives (PN) are used when the clinician documents why they DID NOT perform a procedure. Example: If Aspirin is part of the agency protocol for Chest Pain but was not administered, the reason should be documented. This is done using PN values.

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.

When completing the ePCR it is important to be aware that?

When completing the ePCR, it is important to be aware that: the ePCR allows patient information to be transmitted directly to the receiving hospital's computers. You are providing care to a 61-year-old female complaining of chest pain that is cardiac in origin.

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 “elements”: a duty, a breach of that duty, causation and damages.

What does the EMT say about the patient's wrists?

During the​ call, the patient claims to hear the voice of God and says that the voice is hurting his ears.

What does it mean to document an alcoholic?

Documenting that the patient is an alcoholic is an unverifiable opinion of the patient that is not supported by available facts and could negatively influence other medical providers. You are transporting a city councilman to the hospital after he injured his shoulder playing basketball at his gym.

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.