the patient care report: quizlet paramedic

What happens if a paramedic is unable to complete a report?

If the paramedic is unable to complete his or her patient care report before departing the emergency department, he or she should: A) leave, at a minimum, the patient's name and age, but recognize that the physician will perform his or her own exam.

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?

Who should review a patient care report before submitting?

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. B) the EMS medical director to review the report briefly. C) the paramedic who authored the report to review it carefully. D) the quality assurance team to review the report for accuracy.

What should a paramedic do to ensure accuracy in recording times?

In order to ensure that all recorded times associated with an incident are accurate, the paramedic should: A) frequently glance at his or her watch. B) radio the dispatcher after an event occurs. C) document the time that each event occurs. D) get a copy of the dispatch log after the call.

What should be included in a 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 is a component of the narrative section of a patient care report?

The narrative section of the PCR needs to include the following information: Time of events. Assessment findings. emergency medical care provided. changes in the patient after treatment.

Which of the following is a function of a prehospital care report quizlet?

What are main purposes of the prehospital care report? It serves as a record of patient care, as a legal document, provides information for administrative functions, aids education and research, and contributes to quality improvement.

What is the purpose of Nemsis quizlet?

The National Emergency Medical Services Information System (NEMSIS): collects relevant data from each state and uses it for research. 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.

How do you write a patient report?

III. Patient case presentationDescribe the case in a narrative form.Provide patient demographics (age, sex, height, weight, race, occupation).Avoid patient identifiers (date of birth, initials).Describe the patient's complaint.List the patient's present illness.List the patient's medical history.More items...•

What is a PCR document?

The PCR documentation is considered a medical document that becomes part of the patient's permanent medical record. It is also considered a legal document in cases where liability and/or malpractice issues arise. It is the source in which all medical billing claims are based.

What is the primary purpose 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.

How many sets of vital signs should be included in the patient care report?

At least two complete sets of vital signs should be taken and recorded.

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.

What does Nemsis stand for?

National Emergency Medical Services Information SystemThe National Emergency Medical Services Information System (NEMSIS) is the national database that is used to store EMS data from states and territories. NEMSIS is a universal standard for how patient care information resulting from an emergency 911 call for assistance is collected.

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.

Which aspect of Hipaa is most pertinent to the paramedic?

Which aspect of the HIPAA is MOST pertinent to the paramedic? If your EMS system receives a subpoena for a patient's protected health information, it would be MOST appropriate to: notify legal counsel before releasing any information.

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.

What seven items should be included in the radio report given about a patient?

Parts of the EMS radio report to the hospitalUnit's identification and level of service (ALS or BLS)Patient's age and gender.Estimated time of arrival (ETA)Chief complaint and history of present illness.Pertinent scene assessment findings and mechanism of injury (i.e. fall, or motor vehicle accident)More items...•

Where would a patient's chief complaint normally be found in a narrative that was written using the SOAP format?

Where would a​ patient's chief complaint normally be found in a narrative that was written using the SOAP​ format? In the subjective section. A poorly written patient care​ report: is an invitation for legal action against you.

What is subjective patient information?

Subjective data is gathered from the patient telling you something that you cannot use your five senses to measure. If a patient tells you they have had diarrhea for the past two days, that is subjective, you cannot know that information any other way besides being told that is what happened.

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.