Documentation
Terms
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- Name the 4 uses for PCR's
-
Medical
Administrative
Research
Legal - QA/QI committees use PCR's to identify problems with __________________ paramenics or with the ________ _______________.
- individual, EMS system
- Define PCR
- Prehospital Care Report; the written record of an EMS response
- Your PCR reflects your __________________.
- professionalism
- Your PCR is an important document that helps ensure your patients ______________ ____ _________.
- continuity of care
- Define response time
- Time elapsed from when a unit is alerted until it arrives on the scene
- The __________________ _________________ (QA) or _________________ __________________ (QI) committee will use PCR's to identify problems with individual paramedics or the EMS system.
- quality assurance, quality improvement
- True or false: Your PCR provides the basis for continuously improving patient care in your EMS system.
- True
- A __________________, _______________, and ___________________ account of the emergency call may be your best and only defense in court.
- complete, accurate, objective
- True or false: You need to document your assessment of the patients condition only when arriving on scene and when arriving at the hospital.
- False. A description of the pts condition upon arrival, during care, and when arriving at the hospital should be included. Condition before and after interventions should also be noted. All information should be objective.
- What should be done if you do not know how to spell a word you are trying to use while writing your PCR?
- You should look up the word, or use another word you know how to spell
- _______________ or _________________ words reflect poorly on your professionalism.
- Misspelled, misused
- True or false: As long as you know what your abbreviations or acronyms stand for, that is all you need to be concerned with.
- False. You must be familiar with approved abbreviations and acronyms for your local area.
- Abbreviations
- Abbreviations
- Abdomen
- Abd
- Abdominal pain
- abd pn
- Head, eyes, ears, nose, and throat
- HEENT
- Obstetrical
- OB
- Respiratory
- Resp
- Chest pain
- CP
- Dyspnea on exertion
- DOE
- Fever of unknown origin
- FUO
- Gunshot wound
- GSW
- Headache
- H/A
- No apparent distress
- NAD
- Pain
- pn
- Shortness of breath
- SOB
- Abdominal aortic aneurysm
- AAA
- Acute myocardial infarction
- AMI
- Alcohol
- ETOH
- Chronic obstructive pulmonary disease
- COPD
- Congestive heart failure
- CHF
- Coronary artery bypass graft
- CABG
- CAD
- Coronary artery disease
- DVT
- Deep vein thrombosis
- Diabetes mellitus
- DM
- FBO
- Foreign body obstruction
- HBV
- Hepatitis B virus
- HTN
- Hypertension
- Inferior wall myocardial infarction
- IWMI
- IDDM
- Insulin-dependent diabetes mellitus
- ICP
- Intracranial pressure
- MCI
- Mass casualty incident
- MVC
- Motor vehicle crash
- NIDDM
- Non-insulin-dependent diabetes mellitus
- OD
- Overdose
- PID
- Pelvic inflammatory disease
- G/P
- Pregnancies/Births (Gravida/Para)
- PE
- Pulmonary embolism
- STD
- Sexually transmitted disease
- TIA
- Transient ischemic attack
- Tuberculosis
- TB
- URI
- Upper respiratory infection
- UTI
- Urinary tract infection
- WPW
- Wolff-Parkinson-White syndrome
- ASA
- Aspirin
- Bicarbonate
- HCO-3
- Birth control pills
- BCP
- Calcium
- Ca++
- Calcium chloride
- CaCl2
- Chloride
- Cl-
- Digoxin
- Dig
- Dilantin (phenytoin sodium)
- DPH
- Diphenhydramine
- DPHM
- Diptheria-Pertussis-Tetanus
- DPT
- HCTZ
- Hydrochlorothiazide
- Magnesium sulfate
- Mg++
- MS
- Morphine sulfate
- NTG
- Notroglycerin
- Nonsteroidal antiflammatory agent
- NSAID
- PCN
- Penicillin
- PB
- Phenobarbital
- K+
- Potassium
- NaHCO3
- Sodium bicarbonate
- Sodium chloride
- NaCl
- APAP
- Tylenol
- Anticubital
- AC
- LLL
- Left lower lobe
- LLQ
- Left lower quadrant
- Left upper lobe
- LUL
- Left upper quadrant
- LUQ
- Left ventricle
- LV
- RLL
- Right lower lobe
- RLQ
- Right lower quadrant
- Right middle lobe
- RML
- Right upper lobe
- RUL
- RUQ
- Right upper quadrant
- BBS
- Bilateral breath sounds
- CSF
- Cerebral spinal fluid
- Complete blood count
- CBC
- CT
- Computerized tomography
- Conscious, alert, oriented
- CAO
- EKG, ECG
- Electrocardiogram
- Electroencephalogram
- EEG
- Expiratory
- Exp
- FROM
- Full range of motion
- Full term normal delivery
- FTND
- HR
- Heart rate
- Insp
- Inspiratory
- JVD
- Jugular vein distention
- Laceration
- lac
- Level of consciousness
- LOC
- Moves all extremities
- MAE
- NT
- Nontender
- Palp
- Palpation
- P
- Pulse
- PEARL
- Pupils equal and reactive to light
- PERRLA
- Pupils equal, round, reactive to light, and accomodation
- R
- Respirations
- Unconscious
- unc
- UI
- Urinary incontinence
- ACLS
- Advanced cardiac life support
- ALS
- Advanced life support
- AMA
- Against medical advice
- Automatic external defibrillator
- AED
- Bag-valve mask
- BVM
- BLS
- Basic life support
- Cardiopulmonary resuscitation
- CPR
- CPAP
- Continuous positive airway pressure
- Do not resuscitate
- DNR
- ETT
- Endotracheal tube
- Estimated time of arrival
- ETA
- Intermittent positive-pressure ventilation
- IPPV
- LSB
- Long spine board
- NC
- Nasal cannula
- NG
- Nasogastric
- Nasopharyngeal airway
- NPA
- NPO
- Nothing by mouth
- Orophyngeal airway
- OPA
- O2
- Oxygen
- Short spine board
- SSB
- Rx
- Therapy
- Turned over to
- TOT
- Intracardiac
- IC
- IM
- Intramuscular
- IO
- Intraosseous
- Intravenous
- IV
- j
- Joules
- KVO/TKO
- Keep vein open/To keep open
- Orally
- po
- Subcutaneous
- SC, SQ
- Sublingual
- SL
- Whenever possible, times should be recorded using the same ___________.
- clock or watch
- When it is not possible to use the same watch or clok for recording times, watches should be ________________.
- synchronized
- True or false: If the same watch or clock is not used to record times, and they are not synchronized, it is okay just as long as you make the best guess.
- False. If there is a difference in times, an explanation should be included in the narrative of your PCR.
- Always document the ________________ __________, the orders you received, and the results of implementing that advice and those orders.
- physicians name
- Whenever possible, ____________ the pt or other sources directly. Indicate this by the use of ___________________ _____________.
- quote, quotation marks
- What are the 5 elements of good documentation?
-
Accuracy
Legibility
Timeliness
Absence of alterations
Professionalism - When should your PCR be completed?
- Ideally, immediately after the call
- Define addendum
- Addition or supplement to the origional report
- Define jargon
- Language used by a particular group or profession
- Define libel
- Writing false and malicious words intended to damage a person's character
- Define slander
- Speaking false and malicious words intended to damage a person's character
- What are the 2 approaches to the physical exam (2 types)?
-
Head-to-toe
Body systems - Define field diagnosis
- What you believe to be your patients problem, based on your history and physical exam
- What are the 4 narrative formats?
-
SOAP
CHART
Patient management
Call incident - What does SOAP stand for?
-
Subjective
Objective
Assessment
Plan - What does CHART stand for?
-
Chief complaint
History
Assessment
Rx (treatment)
Transport - The patient assessment format is a ____________________ account of the call.
- chronological
- The call incident approach emphasizes the __________________ ____ _____________, the surrounding circumstances, and how the incident occurred.
- mechanism of injury
- Define AMA
- Against medical advice - your pt refuses care even though you feel he needs it