which of the following statements about the patient care report (pcr) is true?

What does PCR stand for?

Terms in this set (12) 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 needs to be included in the narrative section of PCR?

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 observations at the scene final patient disposition Refusal of care Staff person who continued care How to write a narrative report Standard precautions

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 should be included in multiple-casualty situations on a PCR?

In​ multiple-casualty situations, you must document as much as possible as quickly as possible on your prehospital care report​ (PCR). You can​ then: ignore the rest. complete the documentation later as an addendum. record what should have been done.

What does the patient care report ensure?

The patient care report (PCR) ensures: Continuity of care. After delivering your patient to the hospital, you sit down to complete the PCR.

Which statement shows an accurate understanding of the legal aspects of the prehospital care report PCR )?

Which statement shows an accurate understanding of the legal aspects of the prehospital care report (PCR)? "The PCR may be subpoenaed even if the lawsuit centers on alleged negligence that occurred in the emergency department."

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.

Which format should be used when writing the narrative section of a patient care report?

SOAP NOTE: Traditionally, the SOAP method is used for narrative documentation and includes all pertinent information. SOAP is an acronym for a patient care report that includes: Subjective: details relative to the patient's experience of the illness or injury like onset time, history, complaint, etc.

What is a PCR report?

PCR means polymerase chain reaction. It's a test to detect genetic material from a specific organism, such as a virus. The test detects the presence of a virus if you have the virus at the time of the test. The test could also detect fragments of the virus even after you are no longer infected.

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 should be included in a PCR report?

Follow these 7 Elements to Paint a Complete PCR PictureDispatch & Response Summary. ... Scene Summary. ... HPI/Physical Exam. ... Interventions. ... Status Change. ... Safety Summary. ... Disposition.

What should be included in a narrative PCR?

Present the facts in clear, objective language. Other important details to include are SAMPLE (Signs and Symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events leading up to present injury) and OPQRST (Onset, Provocation, Quality of the pain, Region and Radiation, Severity, and Timeline).

What can you record on a PCR?

This includes the agency name, unit number, date, times, run or call number, crew members' names, licensure levels, and numbers. Remember -- the times that you record must match the dispatcher's times.

When completing the prehospital care report PCR what should be included in it?

According to the NHTSA, in addition to other data elements, the minimum data set on a prehospital care report (PCR) should include all of the following: respiratory rate and effort & skin color and temperature; times of incident, dispatch, and arrival of patient; capillary refill for patients less than 6 years old.

How do you write a PCR narrative in EMS?

The following five easy tips can help you write a better PCR:Be specific. ... Paint a picture of the call. ... Do not fall into checkbox laziness. ... Complete the PCR as soon as possible after a call. ... Proofread, proofread, proofread.

What is the difference between the patient information section of the PCR and the administrative information that is included on the PCR?

What is the difference between the patient information section of the PCR and the administrative information that is included on the​ PCR? The patient information includes specific assessment​ findings, and the administrative information includes the trip times.

As an EMT, the standards of emergency care are often partially based on: Select one: A. Patient care cannot be discredited based on poor documentation. B. EMTs are not liable for any actions that are accurately documented. C. It is difficult to prove actions were performed if they are not included on the report. D. Incomplete reports are common and accepted in EMS.

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

During your monthly internal quality improvement (QI) meeting, you review several patient care reports (PCRs) with the staff of your EMS system. You identify the patient's name, age, and sex, and then discuss the treatment that was provided by the EMTs in the field. By taking this approach to the QI process, you: Select one: A. violated the patient's privacy because you should have discussed the information only with the EMTs involved. B. acted appropriately but must have each EMT sign a waiver stating that he or she will not discuss the cases with others. C. adequately safeguarded the patient's PHI because the cases were discussed internally. D. are in violation of HIPAA because you did not remove the PHI from the PCR beforehand.

D. are in violation of HIPAA because you did not remove the PHI from the PCR beforehand.

In which of the following circumstances can the EMT legally release confidential patient information? Select one: A. The family requests a copy for insurance purposes B. The patient is competent and signs a release form C. A media representative inquires about the patient D. A police officer requests a copy to place on file

B. The patient is competent and signs a release form

In which of the following situations does a legal duty to act clearly exist? Select one: A. The EMT hears of a cardiac arrest after his or her shift ends. B. A call is received 15 minutes prior to shift change. C. A bystander encounters a victim who is not breathing. D. The EMT witnesses a vehicle crash while off duty.

B. A call is received 15 minutes prior to shift change.

Maintaining the chain of evidence at the scene of a crime should include: Select one: A. quickly moving any weapons out of the patient's sight. B. making brief notes at the scene and then completing them later. C. not cutting through holes in clothing that were caused by weapons. D. placing the patient in a private area until the police arrive.

C. not cutting through holes in clothing that were caused by weapons.

Putrefaction is defined as: Select one: A. decomposition of the body's tissues. B. blood settling to the lowest point of the body. C. separation of the torso from the rest of the body. D. profound cyanosis to the trunk and face.

A. decomposition of the body's tissues.

The EMT's scope of practice within his or her local response area is defined by the: Select one: A. medical director. B. state EMS office. C. local health district. D. EMS supervisor.

A. medical director.

To help protect patients, EMS agencies are required to have __________. Select one: A. public forums with their medical director B. online access to patient records C. a privacy officer to answer questions D. an anonymous reporting system

C. a privacy officer to answer questions

When is forcible restraint permitted? Select one: A. Only if consent to restrain is given by a family member B. When the patient poses a significant threat to self or others C. Anytime that the EMT feels threatened D. Only if law enforcement personnel have witnessed threatening behavior

B. When the patient poses a significant threat to self or others

What should be included in maintaining the chain of evidence at the scene of a crime?

Maintaining the chain of evidence at the scene of a crime should include:#N#Select one:#N#A. quickly moving any weapons out of the patient's sight.#N#B. making brief notes at the scene and then completing them later.#N#C. not cutting through holes in clothing that were caused by weapons.#N#D. placing the patient in a private area until the police arrive.

How to respond to a home of a 59 year old man who is unconscious; has slow, shallow breathing

They further state that there is a DNR order for this patient, but they are unable to locate it. You should:#N#Select one:#N#A. begin treatment and contact medical control as needed. #N#B. honor the patient's wishes and withhold all treatment.#N#C. transport the patient without providing any treatment.#N#D. decide on further action once the DNR order is produced.