Chapter 4 - Documentation Flashcards Preview

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

What is a prehospital care report?

PCR - documentation of care provided

1

What is a CQI?

Continuous quality improvement

2

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

3

What is minimum data set?

The information the DOT wants on all PCRs

4

What is objective information?

Information is measurable or verifiable in some way

5

What is subjective information?

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

6

What are pertinent negatives?

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

7

What does SOAP stand for?

Subjective
Objective
Assessment
Plan

8

What does CHART stand for?

Chief complaint
History
Assessment
Rx
Transport

9

What does CHEATED stand for?

Chief complaint
History
Exam
Assessment
Treatment - evaluation - disposition

10

What does SOT stand for?

Subjective
Objective
Treatment and transport