Chapter 4 - Documentation Flashcards Preview

EMT - Basic - Prehostpital Emergency Care 10th Edition > Chapter 4 - Documentation > Flashcards

Flashcards in Chapter 4 - Documentation Deck (7)
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1

information measurable or verifiable in some way.

objective

2

information based on an individuals perceptions or interpretations.

subjective

3

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

pertinent negative

4

basic information - chief complaint, vital signs, and treatment provided - recorded on a:

triage tag

5

information that needs to be documented on the prehospital care report:
SOAP

subjective
objective
assessment
plan

6

information that needs to be documented on the prehospital care report:
CHART

chief complaint
history
assessment
Rx
transport

7

information that needs to be documented on the prehospital care report:
CHEATED

chief complaint
history
exam
assessment
treatment
evaluation
disposition

Decks in EMT - Basic - Prehostpital Emergency Care 10th Edition Class (44):