Chapter 4 - Documentation Flashcards Preview

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Flashcards in Chapter 4 - Documentation Deck (11)
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0
Q

What is a CQI?

A

Continuous quality improvement

1
Q

What is a prehospital care report?

A

PCR - documentation of care provided

2
Q

What are the 2 basic rules of filling out any PCR?

A

If it wasn’t written down it wasn’t done

If it wasn’t done don’t write it down

3
Q

What is minimum data set?

A

The information the DOT wants on all PCRs

4
Q

What is objective information?

A

Information is measurable or verifiable in some way

5
Q

What is subjective information?

A

Information that is based on an individual’s perceptions or interpretations

6
Q

What are pertinent negatives?

A

Signs or symptoms that might be expected, based on the chief complaint, but the patient denies having

7
Q

What does SOAP stand for?

A

Subjective
Objective
Assessment
Plan

8
Q

What does CHART stand for?

A
Chief complaint
History
Assessment
Rx
Transport
9
Q

What does CHEATED stand for?

A
Chief complaint
History
Exam
Assessment
Treatment  - evaluation - disposition
10
Q

What does SOT stand for?

A

Subjective
Objective
Treatment and transport