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