which of the following is correct regarding a patient care report?

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:

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.

When documenting the patient's last blood pressure reading you should?

When documenting the patient's last blood pressure reading, you inadvertently write 120/60 instead of 130/70. To correct this mistake, you should: A. leave the error on your PCR but inform the staff of the patient's actual blood pressure.

What is included in 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. The documentation included on the PCR provides vital information, which is necessary for continued care at the hospital.

When must a patient care report be completed?

Complete the PCR as soon as possible after a call Most states, and many EMS agencies themselves, often have time limits within which the PCR must be completed after the call ended – 24, 48 or 72 hours are common time limits.

Why should a patient care report be detailed?

Importance of Documentation The purpose of record documentation is to provide an accurate, comprehensive permanent record of each patient's condition and the treatment rendered, as well as serving as a data collection tool.

When you document information on a patient that you treat and care for this written report is called the?

When you document information on a patient that you treat and care for. This written report is called the: Patient care report, run report. You are asked to give testimony in court about the care you gave to a patient.

How do you complete 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.

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...•

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.

Which of the following is the most important information about the patient that an emergency medical responder should give when transferring care?

Which of the following is the most important information about the patient that an emergency medical responder should give when transferring care? Chief complaint. Your patient care report may be called into a civil or criminal court due to the fact that: It is considered a legal document.

What is patient care documentation?

Documentation typically reports why the patient was seen, what was done, what was found, and what was recommended in a way that justifies the assigned diagnosis and procedure codes (see Coding/Billing for Reimbursement). Health plans reviewing claims will ask for documentation to justify the services delivered.

Which of the following are components necessary for proper documentation in a patient's medical chart?

What Are The 10 Components Of A Medical Record?Identification Information. One of the first important components you can find in medical records is the identification information. ... Medical History. ... Medication Information. ... Family History. ... Treatment History. ... Medical Directives. ... Lab results. ... Consent Forms.More items...•

What is proper documentation in healthcare?

Some key factors of effective healthcare documentation include: Provide factual, consistent, and accurate input. Update the information after any recordable event. Make sure all information is current. Confirm that all entries are legible and signed.

Is it difficult to prove actions were performed if they are not included on the report?

A. It is difficult to prove actions were performed if they are not included on the report.

Can a patient refuse to be transported?

A. A patient can consent to transport but can legally refuse to be treated.

What is the difference between a medical report and a trauma report?

C) Medical reports describe a chief complaint while trauma reports do not.

Who is mandating simultaneous transmission of your verbal report and telemetry data on all cardiac patients?

The medical director for your agency is mandating simultaneous transmission of your verbal report and telemetry data on all cardiac patients. This will​ require:

What happens when you wheel a patient through the emergency department doors?

As you are wheeling your patient through the emergency department doors, you receive another call for a major motor vehicle crash. You should:

How to help a 4-year-old with a seizure?

His father is sitting in a nearby chair. The child's mother suddenly begins crying uncontrollably, which causes the child to start crying. You should:#N#Select one:#N#A. attempt to calm the child's mother, but avoid separating her from her child because this will increase her anxiety.#N#B. give the child a favorite toy or blanket to hold onto and perform your assessment to the best of your ability.#N#C. consider asking the father to hold the child so you can assess him while your partner tries to calm the mother.#N#D. reassure the child's mother that seizures in children are very common and that there is nothing to worry about.

What causes a 4-year-old to cry?

A 4-year-old boy had an apparent seizure. He is conscious and calm and is sitting on his mother's lap. His father is sitting in a nearby chair. The child's mother suddenly begins crying uncontrollably, which causes the child to start crying. You should:

What does it mean when a child has red marks on his back?

The child's parents explain that these marks represent coining—a traditional Asian healing practice in which hot coins are rubbed on the back.

What does "d" mean in a police report?

D. the general geographic location of the incident.

What is sentinel event?

D. This is incorrect. A sentinel event is an unexpected occurrence that results in death or serious permanent injury. A hemolytic transfusion reaction caused by incompatible blood is a shocking event that should never occur.

What is risk management?

D. This is incorrect. Risk management is a process involving identification, analysis, treatment, and evaluation of both real and potential hazards.

How many adverse drug events are preventable?

C. This is incorrect. According to the Agency for Healthcare Quality and Research (AHRQ, 2017b) as many as 50% of adverse drug events were preventable.

What is equitable care?

C. This is incorrect. Equitable care is provided by ensuring all patients receive the same care, regardless of patient characteristics.

How many medication errors are preventable?

C. As many as 90% of medication errors are preventable.

What does "RN" mean in medical terms?

A. A registered nurse ( RN) who made a major medication error was terminated.

Why is it important to determine why errors occur and working to eliminate them?

A. This is incorrect. Determining why errors occur and working to eliminate them is the best way to promote safety.