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PATIENT CARE REPORT (PCR)
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CONTINUITY OF CARE
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CHAPTER 8
CHAPTER 8PRINCIPLES OF EFFECTIVE DOCUMENTATION
| Question | Answer |
|---|---|
| PATIENT CARE REPORT (PCR) | A DOCUMENT THAT PROVIDES DETAILS ABOUT A PROVIDES DETAILS ABOUT A PATIENTS CONDITIONS HISTORY AND CARE AS WELL AS INFORMATION ABOUT THE EVENT THAT CAUSED THE ILLNESS OR INJURY |
| CONTINUITY OF CARE | REFERS TO HOW EACH PROVIDER WHO IS ASSUMING CARE FOR A PATIENT IS PROPERLY INFORMED OF THE PATIENT PROGRESSION SO HE OR SHE CAN WATCH FOR TRENDS AND CONTINUE EFFECTIVE TREATMENTS |
| CONTINUITY OF CARE (SHORT VERISON) | YOUR REPORT MANY BE REFERENCED BY OTHER CARE PROVIDERS ON THE EMS TEAM OR AT THE HOSPITAL |
| EDUCATION | YOUR WRITTEN REPORT MAY BE USED AS AN EXAMPLE FOR OTHERS OF PROPER OR NOT SO PROPER DOCUMENTATIONS |
| ADMINISTRATION | THE REPORT WILL BE USED FOR THE COMPILING OF STATISTICAL ANALYSIS ON ISSUED THAT AFFECT YOUR AGANCY OR COMMUNITY |
| QUALITY ASSURANCE | REPORTS CREATED BY YOUR AND OTHERS IN YOUR AGENCY OR ORGANIZATION MAY BE REVIEWED AS PART OF A STRUCTURED PROCESS TO IMPROVE THE OVERALL QUALITY OF THE CARE YOUR AGENCY PROVIDES AS WELL AS THAT OF THE EMS SYSTEM AS A WHOLE |
| LEGAL | THE REPORT YOU CREATED IS A LEGAL DOCUMENT. IT MAY BE USED IN A CIVIL OR CRIMINAL COURT FOR ANY NUMBER OF REASONS |
| DOCUMENT, DOCUMENT, DOCUMENT | THE OLD SAYING "IF YOU DIDN'T DOCUMENT IT, YOU DIDN'T DO IT" IS TRUE WHEN IT COMES TO PATIENT CARE REPORT (PCR) |
| RUN DATA | THIS SECTIONS INCLUDES INFORMATION ABOUT THE CALL ITSELF SUCH AS THE NAMES OF THE EMERGENCY MEDICAL RESPONDERS TAKING ACTION THE AGENCY THEY WORK FOR THE DATE AND TIME OF THE INCIDENT AND EVEN CERTIFICATION LEVELS OF THOSE PROVIDING PATIENT CARE |
| PATIENT DATA | NAME ADDRESS D0B,GENDER -NATURE OF THE CALL-DETAILED NOTES ON THE PT COMPLAINT-MECHANISM OF INJURY-ASSESSMENT FINDINGS-CARE ADMINISTERED PRIOR TO ARRIVAL OF EMR-VITAL SIGNS-PAST MED HISTORY-CHANGES IN THE PT COND-TREATMENT PROVIDED AND THE PT RESPOND |
| FILL-IN | DATA IS PLACED IN SPECIFICALLY LABELED SPACES |
| CHECK BOXES | SOME PCRS HAVE BOXES THAT CAN BE CHECKED FOR INFORMATION SUCH AS PATIENT HISTORY NATURE OF ILLNESS AND CARE PROVIDED |
| NARRATIVE | SPACE IS PROVIDED FOR YOU TO WRITE THE STORY DOC THE PATIENTS HISTORY ASSESSMENT OR CARE INFO THAT DOES NOT OTHERWISE FIT IN CHECK BOXES OR THAT REQUIRES EXPANSION ON THE DETAILS. OFTEN THE NARRATIVE WILL CONTAIN A BLEND OF BOTH OBJECTIVE AND SUBJECTIVE |
| MINIMUM DATA SET | THE MINIMUM INFORMATION REQUIRED BY THE US DEPARTMENT OF TRANSPORTATION (DOT) STANDARDS FOR EACH PATIENT TYPICALLY APPLIES TO ONLY 911 CALLS |
| THE NARRATIVE | THE STORY YOU TELL THROUGH THE NARRATIVE SHOULD BE CLEAR CONCISE AND AS OBJECTIVE AS POSSIBLE |
| OBJECTIVE INFORMATION | THIS INFORMATION IS IMPARTIAL AND UNBIASED, SOMETHING YOU CAN SEE HEAR FEEL OR MEASURE |
| LIST OF SIGNS WHEN CARING FOR A PATIENT | PULSE RATE - SKIN COLOR - BREATHING RATE - BLOOD PRESSURE - SWELLING - BRUISING - THE FACT THAT THE PATIENT VOMITED |
| SUBJECTIVE INFORMATION | THIS INFORMATION IS OFTEN THE OPINION OF THE EMR AND IS INFLUENCED BY PERCEPTION PERSONAL FEELINGS AND PRIOR EXPERIENCE |
| SUBJECTIVE - SYMPTOMS - THINGS THAT A PATIENT DESCRIBES SUCH AS: | PAIN, DISCOMFORT, FEELING, NAUSEATED, OR FEELING LIGHT HEADED ARE ALL SUBJECTIVE FINDINGS |
| ELECTRONIC DOCUMENTATION | REFERS TO TECHNOLOGY SUCH AS LAPTOP COMPUTERS ELECTRONIC TABLETS AND CELL PHONES AND THEIR USE TO DOCUMENT PATIENT CONDITION AND CARE |
| CORRECTING ELECTRONIC ERRORS | ERRORS MADE WHILE USING AN ELECTRONIC PCR PROGRAM TYPICALLY REQUIRE THAT YOU SUBMIT AN ELECTRONIC DOCUMENTATIONS ADDENDUM TOT HE ORIGINAL REPORT |
| IT IS IMPORTANT FOR THE EMR TO HAVE A GENERAL UNDERSTANDING OF THE DIFFERENT PATIENT CARE DOCUMENTATION TOOLS | PAPER FORM - COMPUTER SCAN FORM - LAPTOP/TABLET COMPUTERS - SMARTPHONES APPLICATIONS |
| PCRs ARE USED FOR ALL OF THE FOLLOWING - EXCEPT: | PRESS RELEASE |
| CONTINUITY OF CARE IS BEST DESCRIBED AS: | THE THOROUGH AND CONSISTENT DELIVERY OF CARE AMONG ALL PROVIDERS |
| YOU ARE WRITING THE PATIENTS HISTORY ON A PCR AND INADVERTENTLY DOCUMENT AN INCORRECT MEDICATION. YOU SHOULD: | DRAW A SINGLE LINE THROUGH THE ERROR, WRITE THE CORRECT MEDICATION AND INITIAL THE CHANGE |
| AFTER CARING FOR A PATIENT YOU DOCUMENT THE DETAILS OF THE CALL ON THE COMPANY PROVIDED TABLET, UPLOADING THE INFORMATION INTO THE COMPANY DATABASE. THIS IS AN EXAMPLE OF WHICH TYPE OF DOCUMENTATION | ELECTRONIC PCR |
| WHICH ONE OF THE FOLLOWING WOULD (NOT) BE APPROPRIATE TO INCLUDE IN A STANDARD EMERGENCY MEDICAL RESPONDER PCR? | THE EXACT LOCATION WHERE THE PATIENT WAS INITIALLY CONTACTED |
Created by:
mmfleischer