"which of the following should be left out of a patient care report"

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:

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.

Should incident reports be included in the patient's nursing notes?

D When charting the incident in the patient's nursing notes, do not mention the incident report. While doing clinicals, your nurse preceptor had to leave her station immediately due to a code overheard on the public address system. You observed that the computer monitor displayed a patients medical history.

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 things should be included on 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.

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 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.

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 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.

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.

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 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...•

Which of the following is not a recommendation for safe lifting?

Do not attempt to lift by bending forward. Bend your hips and knees to squat down to your load, keep it close to your body, and straighten your legs to lift. Never lift a heavy object above shoulder level. Avoid turning or twisting your body while lifting or holding a heavy object.

Which of the following is a patient responsibility?

Patients are responsible for keeping appointments. Patients are responsible for treating others with respect. Patients are responsible for following facility rules regarding smoking, noise, and use of electrical equipment. Patients are responsible for what happens if they refuse the planned treatment.

Which of the following is an appropriate means of communicating with patients who are not fluent in English?

Some physicians may simply be uncomfortable with the potential for information distortion that can occur through an interpreter. Another common approach to communicating with patients who do not speak English is to use ad hoc interpreters such as family members, friends, or hospital employees.

When caring for a patient who does not speak English how do you obtain information from the patient?

7 tips for communicating with patients who don't speak EnglishIdentify the language gap and build trust. ... Use Google Translate. ... Use a professional interpreter to convey medical information. ... Learn key phrases. ... Mind nonverbal cues and be compassionate. ... Mime things out. ... Use gestures. ... Consider the role cultural differences play.More items...•