which of the following constitutes minimum data that must be included on every patient care report?

What should be included in the report of a diabetic patient?

A) Chief complaint, level of consciousness, vital signs, assessment, and patient's age and gender B) Level of consciousness, field impression, vital signs, assessment, and patient's name and address C) Scene size-up, detailed assessment, blood glucose reading, vital signs, and patient's age

What should the patient care report include?

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.

When to advise the receiving provider of a completed patient care report?

D) advise the receiving provider that he or she will return to the emergency department with the completed patient care report within 24 hours. 35. Additions or notations added to a completed patient care report by someone other than the original author:

Where can I find Chapter 6 documentation flashcards?

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What elements are typically included in the 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 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 is most important for the paramedic to?

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.

What are 3 elements of getting and documenting a refusal of care?

This can be accomplished by using the CASE CLOSED acronym for bulletproof documentation of a refusal. C = Condition, Capacity, and Competence—The documentation should include the patient's chief complaint(s) in the patient's own words.

What are the 5 essential elements of the informed consent process?

Obtaining informed consent in medicine is process that should include: (1) describing the proposed intervention, (2) emphasizing the patient's role in decision-making, (3) discussing alternatives to the proposed intervention, (4) discussing the risks of the proposed intervention and (5) eliciting the patient's ...

What 3 elements must a patient demonstrate in order for a refusal to be lawful?

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 ...

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.

Which of the following refers to the care that would be expected to be provided by an EMT with similar training when caring for a patient in a similar situation?

The care that would be expected to be provided to the same patient under the same circumstances by another EMT who had received the same training is called the: standard of care.

What clinical patient information is included in the Minimum data Set on a PCR?

MINIMUM DATA SET: two separate types of data that are recorded,PATIENT INFORMATION: chief complaint, the initial assessment, vital signs, and. patient demographics.ADMINISTRATIVE INFORMATION: the time the incident was reported, the time the responding unit was notified, the time of arrival at the patient,

What is pertinent positive data?

An element of a patient's history that aids diagnosis because the patient affirms that it is present.

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.