Flashcards in Chapter 4 - Documentation Deck (11):
What is a prehospital care report?
PCR - documentation of care provided
What is a CQI?
Continuous quality improvement
What are the 2 basic rules of filling out any PCR?
If it wasn't written down it wasn't done
If it wasn't done don't write it down
What is minimum data set?
The information the DOT wants on all PCRs
What is objective information?
Information is measurable or verifiable in some way
What is subjective information?
Information that is based on an individual's perceptions or interpretations
What are pertinent negatives?
Signs or symptoms that might be expected, based on the chief complaint, but the patient denies having
What does SOAP stand for?
What does CHART stand for?
What does CHEATED stand for?
Treatment - evaluation - disposition