chapter 19 - documentation Flashcards Preview

Block 4 test > chapter 19 - documentation > Flashcards

Flashcards in chapter 19 - documentation Deck (11):
1

health insurance portability and accountability act

HIPPA - rules governing the protection of a patients identifiable information

2

medical terminology

greek and latin based words that function as a common language for the medical community

3

objective information

verifiable findings, such as information seen, felt, or heard by the paramedic

4

pertinent negative

in a patient assessment, the signs and symptoms found to be present that support a working diagnosis

5

prefix

added to the beginning of a root word to alter the meaning. Usually identifies location or frequency

6

prehospital care report

PCR - the report written by the paramedic after the call has been completed. The report becomes part of the patient's permanent record

7

root word

in medical terminology, the part of the word that gives the primary meaning

8

scope of practice

the set of procedures a paramedic is allowed and expected to perform

9

subjective information

information told to the paramedic

10

suffix

added to the end of a root word to change the meaning. usually identifies the condition of the root word.

11

trip audit

the review of a PCR written by a paramedic by a peer or a third party