CHAPTER 8PRINCIPLES OF EFFECTIVE DOCUMENTATION
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| PATIENT CARE REPORT (PCR) | show 🗑
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| CONTINUITY OF CARE | show 🗑
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| show | YOUR REPORT MANY BE REFERENCED BY OTHER CARE PROVIDERS ON THE EMS TEAM OR AT THE HOSPITAL
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| EDUCATION | show 🗑
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| show | THE REPORT WILL BE USED FOR THE COMPILING OF STATISTICAL ANALYSIS ON ISSUED THAT AFFECT YOUR AGANCY OR COMMUNITY
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| show | 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
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| LEGAL | show 🗑
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| DOCUMENT, DOCUMENT, DOCUMENT | show 🗑
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| show | 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
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| show | 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
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| FILL-IN | show 🗑
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| CHECK BOXES | show 🗑
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| show | 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
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| show | THE MINIMUM INFORMATION REQUIRED BY THE US DEPARTMENT OF TRANSPORTATION (DOT) STANDARDS FOR EACH PATIENT TYPICALLY APPLIES TO ONLY 911 CALLS
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| show | THE STORY YOU TELL THROUGH THE NARRATIVE SHOULD BE CLEAR CONCISE AND AS OBJECTIVE AS POSSIBLE
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| OBJECTIVE INFORMATION | show 🗑
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| show | PULSE RATE - SKIN COLOR - BREATHING RATE - BLOOD PRESSURE - SWELLING - BRUISING - THE FACT THAT THE PATIENT VOMITED
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| show | THIS INFORMATION IS OFTEN THE OPINION OF THE EMR AND IS INFLUENCED BY PERCEPTION PERSONAL FEELINGS AND PRIOR EXPERIENCE
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| show | PAIN, DISCOMFORT, FEELING, NAUSEATED, OR FEELING LIGHT HEADED ARE ALL SUBJECTIVE FINDINGS
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| ELECTRONIC DOCUMENTATION | show 🗑
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| show | ERRORS MADE WHILE USING AN ELECTRONIC PCR PROGRAM TYPICALLY REQUIRE THAT YOU SUBMIT AN ELECTRONIC DOCUMENTATIONS ADDENDUM TOT HE ORIGINAL REPORT
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| show | PAPER FORM - COMPUTER SCAN FORM - LAPTOP/TABLET COMPUTERS - SMARTPHONES APPLICATIONS
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| PCRs ARE USED FOR ALL OF THE FOLLOWING - EXCEPT: | show 🗑
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| show | THE THOROUGH AND CONSISTENT DELIVERY OF CARE AMONG ALL PROVIDERS
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| show | DRAW A SINGLE LINE THROUGH THE ERROR, WRITE THE CORRECT MEDICATION AND INITIAL THE CHANGE
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| 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 | show 🗑
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| WHICH ONE OF THE FOLLOWING WOULD (NOT) BE APPROPRIATE TO INCLUDE IN A STANDARD EMERGENCY MEDICAL RESPONDER PCR? | show 🗑
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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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Created by:
mmfleischer