Flashcards in Chapter 4 Documentation Deck (33)
what is the most common type of record that is prepared in a pre-hospital setting?
Pre-hospital care report (PCR)
What is the function of a pre-hospital care report (PCR).
Continuity of care
What is Continuity of care
Refers to the coordination of care between heath care personnel and the patient during the course of their illness or injury.
EMT’s start this process by giving a baseline against which that patient’s improvement or deterioration can be measured.
What is the Administrative Uses of a (PCR)
(PCR) become apart of a patients permanent hospital record for billing & insurance and it may be used for statistical research.
When does a (PCR) become a Legal Document
a run that EMT'S is involved in can be a crime scene or end up a civil lawsuits. EMT will need to refer to the run sheet while in court.
How is a (PCR) use in educational and research uses?
scientists and researchers use the date on PCR to evaluate positive/negative effects during different stages of patient contact. Administrators look for was to make care more efficient and improve training programs.
How does (PCR) help with evaluation and continuous quality improvement?
Medical oversight committees use data to ensure that EMTs are adhering to protocols and standard of care. Data in PCR show area's that need improvement for training.
What are some other names for a PCR?
run sheet or trip sheet
what is the most traditional format for a PCR?
What is an alternative to a written PCR?
computer direct data entry report
What are the two basic rules of a PCR?
1) If it was written down, it wasn't done
2) If it wasn't done, don't write it down
What is a minimum data set?
it is data that is required on a PCR by the department of transportation (DOT).
What is included in Patient Information in a minimum data set?
Level of responsiveness (AVPU) -mental status
skin color, temperature, & condition
respiratory rate & effort
patient demographics (age, sex, race, weight)
What is included in Administrative Information (run data)
Time incident was reported
Time unit was notified
Time of arrival at the patient
Time the unit left the scene
Time the unit arrived at its destination (hospital etc)
Time of transfer of care
EMS Unit number
Name of crew & cert levels
What is the third major division of the PCR?
What information should be included in the Vital Signs?
Ideally 2 sets of vitals
patients position when taken
What is the Patient Narrative on the PCR?
this section give detailed information about the patient and what their problem is
The narrative contains what?
1) The patients chief complaint (in patients words)
2) The patients history or a description of the mechanism of injury - when/how
What is objective information?
Information that is measurable and verifiable.
i.e. pulse, color of skin etc
What is subjective information?
information based on an individuals perceptions or interpretations.
i.e. the patient seems to be in pain
The information should be pertinent; it should relate to the medical circumstances.
What are Pertinent Negatives
Signs and symptoms that might be expected based on chief complaint, but the patient denies having.
i.e denial of pain after an automobile accident
What is the Treatment section of the PCR contain?
the chronological treatment that was provided to the patient
Confidentiality of (PCR)
Keep patient information private
Distribution of (PCR)
Follow local and state rules
You can give information to health care provider that is apart of continuity of care process.
copy of PCR given to patient
Refusal of treatment of (PCR)
Be sure to document everything regarding refusal
Falsification of (PCR)
when there is an error on PCR it must be highlighted.
document exactly what did or didn't happen.
EMT can lose license and face criminal charges for falsify info on PCR
How do you correct errors on a PCR?
in written form - draw a single horizontal line through the error, initial it, and write the correct information next to it.
if found after submitted to same as above also add date and time and do it in different color ink.
electronically: print a copy of report and do the steps above.
in what situation would a standard PCR not be appropriate?
exposure to an infectious diseases
other situation that an EMT feels needs to be reported to an agency
When would an EMT use an abbreviated transfer-of care form or a drop report?
In situations where the EMT has to return immediately to the field to answer another call or when there is no way to print a hard copy.
What is a triage tag?
It is a tag used during a multiple causality situation that is placed on a patient with their basic information.
What are 3 alternative mnemonic methods use to organize information on a PCR?
What does Soap stand for?
S - subjective - info told to you
O- objective - info from doing inspection, palpation, auscultation
A- assessment - field assessment
P-plan- action & emergency care plan