Effective Documentation Chapter 7 Flashcards Preview

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What are some of the common terms used to describe patient care reports?

Run report
Patient care report
Prehospital care report


What is the purpose of the patient care report (PCR)?

To document the care you performed as part of a patient permanent record.


Define patient care report (PCR).

A document that provides details about a patient's condition, history, and care, as well as information about the event that caused the illness or injury.


What are the five (5) reasons for the need of accurate and complete documentation?

1. Continuity of care
2. Education
3. Administration
4. Quality assurance
5. Legal


Define continuity of care.

This refers to how each new provider assuming care for a patient, is properly informed of the patients progression, so they can watch for trends and continue effective treatments.


Define minimum data set.

The essential information that must be gathered and documented on every patient care report (PCR).


What are the common elements of the PCR?

Run data -
Information about the call itself, such as the names of the EMR's responding, the organization they work for, and the date and time of the incident, including certification levels. It may also include the final outcome of the call, such as patient's refusal to be treated where the name of the person who assumes patient care from you. All names, times, and locations recorded on the PCR must be accurate since continued care, billing, and statistical information will all depend on the information provided.

Patient data -
Name, address, date of birth, sex
Nature of the call
Detailed notes on the patients complaint
Mechanism of injury and assessment
Care administered prior to arrival of EMR's
Vital signs
Sample history
Changes in the patient's condition


What type of information should you write in your narrative, objective or subjective?

Objective: Objective information is comprised of straight forward facts.
Example "The patient's right forearm was swollen and angulated" is objective.


Is the statement, "I believe the patient was attempting to perform a dangerous trick on his skateboard" subjective or objective?

Subjective: Subjective information is up to interpretation and may even include descriptions of how people feel about something.

EMR reporting should be objective statements comprised of straightforward facts only.


Describe the minimum data set required for the documentation of patient care by the US Department of Transportation (DOT).

1. Time the incident was reported to 911
2. Time of dispatch
3. Time of arrival at the patient's location
4. Time the patient was transported from the incident location
5. Time the patient arrived at the destination (hospital, aid station, etc.)
6. Time the patient care was transferred to more advanced providers
7. Patient's chief complaint
8. Patient's vital signs
9. Patient's demographics (age, gender, race, weight)


Explain the procedure for correcting errors made during documentation.

1. Cross out the incorrect item with a single line, and initial it, and
2. Write the correct information beside or about it. Note: Never completely cover the incorrect information, because it may appear that you were attempting to hide something.


What are the five (5) methods used for documentation of patient care in the field setting?

1. Paper forms
2. Computer scan forms
3. PDAs
4. Laptop computers
5. Data enabled cellular devices


Patient care reports are used for all of the following except:
A. billing
B. press releases
C. quality improvement
D. lawsuits

B. press releases


Continuity of care is best described as:
A. ensuring that the same care provider is responsible for treating a patient until admission to the hospital
B. ensuring that once a particular treatment is started it is not stopped
C. the process where each new care provider is properly updated about the patients progression
D. the proper documentation of the care provided to a patient

C. the process where each new care provider is properly updated about the patients progression


You are writing the patient's history on a PCR and inadvertently document an incorrect medication. You should:
A. discard the document and begin again
B. completely mark out the incorrect medication name with your pens and no one will be able to see it and become confused
C. not worry about it, since EMR's do not administer medications
D. correct the error with a single, initialed line

D. correct the error with a single, initialed line


"The patient complained of chest pain, but I believe that he was just trying to avoid getting a speeding ticket", is an example of what type of statement:
A. subjective
B. pertinent
C. objective
D. erroneous

A. subjective


Which one of the following would not be included in a standard EMR patient care report?
A. the exact location where the patient was initially contacted
B. that the patient was suffering from a heart attack
C. the names of the ambulance personnel who assumed care of the patient
D. the cause of the injury

B. that the patient was suffering from a heart attack