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
Q

information measurable or verifiable in some way.

A

objective

2
Q

information based on an individuals perceptions or interpretations.

A

subjective

3
Q

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

A

pertinent negative

4
Q

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

A

triage tag

5
Q

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

A

subjective
objective
assessment
plan

6
Q

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

A
chief complaint
history
assessment
Rx
transport
7
Q

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

A
chief complaint 
history
exam
assessment
treatment
evaluation
disposition

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