which of the following is the least important to document on 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.

What is a patient care report (PCR)?

Patient care report (PCR) Prehospital care report, is the legal document used to record all aspects of the care your patient recieved, from initial dispatch to arrival at the hospital The report serves the following six functions :

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 is the minimum data set in a patient care report?

The Minimum Data Set (MDS) is part of a federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process entails a comprehensive, standardized assessment of each resident's functional capabilities and health needs.

Which of the following concepts is the first and most important when providing patient care quizlet?

Which of the following concepts is the first and MOST important when providing patient care? To comply with the standard of care, the EMR must: Treat the patient to the best of his or her ability and provide care that a reasonable, prudent person with similar training would provide under similar circumstances.

Why is it important to not give the name or Social Security number of your patient over the ambulance radio when contacting medical control?

Why is it important to not give the name or Social Security number of your patient over the ambulance radio when contacting medical​ control? It is illegal. You have received an order from medical direction that you feel would be detrimental to your patient.

What is the 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.

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 makes good patient care?

It means providing care that is free from harm, minimizes redundancy and waste, allows timely access to needed services, follows best practices, and incorporates patients' preferences and treatment priorities.

Which of the following would be the Emrs most important initial responsibility when arriving at the scene of a multiple patient incident?

Which of the following would be the EMR's most important initial responsibility when arriving at the scene of a multiple-patient incident? Assessing the environment to dectect possible threats to his or her safety.

What is involved in the primary assessment?

the six parts of primary assessment are: forming a general impression, assessing mental status, assessing airway, assessing breathing, assessing circulation, and determining the priority of the patient for treatment and transport to the hospital.

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

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.

Why is documentation important in EMS?

The primary purpose of EMS documentation is to provide a written record of patient assessment and treatment that can help guide further care. For the information to be readily understood and communicated, it must be organized in a format that all healthcare providers involved in patient care will understand.

Is documentation important in EMS?

First and foremost, EMS documentation serves a vital clinical purpose. It is the record of your assessment and care of patients. It becomes part of the patient's medical record, both at the receiving facility and within your EMS organization.

Why do you need to correct an error?

you need to correct an error to ensure that the information is accurate.

Why do you not initiate CPR?

While functioning at the scene of a patient in cardiac arrest, you do not initiate CPR because the patient is elderly and you think that he is probably dead. Paramedics arrive and determine that the patient has only been in cardiac arrest for 6 minutes.

What to do if a patient changes his mind?

advise the patient to call EMS if he changes his mind.

Can you be held liable for failure to follow the standard of care?

you may be held liable for failure to follow the standard of care.

Can you move furniture if it interferes with patient care?

avoid moving furniture unless it interferes with patient care.

What chapter is Emergency Care in the Streets?

Emergency Care in the Streets Chapter 6: Documenta…

What should a paramedic do before leaving the emergency department?

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 is a C billing system?

C) is a nationwide billing system that any EMS provider can use.

Do insurance companies pay if unapproved abbreviations are used?

D) insurance companies do not pay if unapproved abbreviations are used .

What is a prehospital care report?

Prehospital care report, is the legal document used to record all aspects of the care your patient recieved, from initial dispatch to arrival at the hospital

What do you do if a patient refuses care?

Even if the patient refuses care, you must complete the PCR. You will need to document the advice you gave as to the risks associated with refusal of care.

What does "not allow a complete assessment" mean?

f the patient refuses care or did not allow a complete assessment, document that the patient did not allow for proper assessment and document whatever assessments were completed

What happens if you refuse to take care of a patient?

Typically these consequences should be listed and clear to include the possibility of severe illness/injury or death if you care or transportation is refused.

What are the alternatives to seeing a doctor?

providing the patient with other alternatives: going to see his or her family doctor, having a family member drive him or her to the hospital

What is the recording of information in a patient's medical record?

the recording of information in a patient's medical record; includes detailed notes about each contact with the patient and about the treatment plan, patient progress, and treatment outcomes.

What is the purpose of a patient record review?

to examine and review a group of patient records for completeness and accuracy-particularly as related to their ability to back up the charges sent to health insurance carriers for reimbursement.

What does C stand for in a complaint?

C: Chief complaint H: History E: Examination D: Details of problem and complaint D: Drugs and dosage A: Assessment R: Return visit information or referral, if applicable

What is a medical history compilation?

a compilation of important information about a patient's medical history and present condition

How to correct an error in a word?

draw a line through the error; make the correction as close as possible to the original entry; note the reason for the correction; sign and date the correction