Chapter 4 - Documentation

Question 0

What is a CQI?

Answer 0

Continuous quality improvement

Question 1

What is a prehospital care report?

Answer 1

PCR - documentation of care provided

Question 2

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

Answer 2

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

If it wasn’t done don’t write it down

Question 3

What is minimum data set?

Answer 3

The information the DOT wants on all PCRs

Question 4

What is objective information?

Answer 4

Information is measurable or verifiable in some way

Question 5

What is subjective information?

Answer 5

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

Question 6

What are pertinent negatives?

Answer 6

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

Question 7

What does SOAP stand for?

Answer 7

Subjective
Objective
Assessment
Plan

Question 8

What does CHART stand for?

Answer 8

Chief complaint
History
Assessment
Rx
Transport

Question 9

What does CHEATED stand for?

Answer 9

Chief complaint
History
Exam
Assessment
Treatment  - evaluation - disposition

Question 10

What does SOT stand for?

Answer 10

Subjective
Objective
Treatment and transport