What should be included in the patient care report?
The patient care report: A) provides for a continuum of patient care upon arrival at the hospital. B) is a legal document and should provide a brief description of the patient. C) should include the paramedic's subjective findings or personal thoughts. D) is only held for a period of 24 months, after which it legally can be destroyed.
How accurate is my Patient Care report?
The accuracy of your patient care report depends on all of the following factors, EXCEPT: A) including all pertinent event times. B) the severity of the patient's condition. C) the thoroughness of the narrative section.
Can a patient care report be revised after submission?
A) The original patient care report should be destroyed if a revision is necessary. B) Only the person who wrote the original report can revise or correct it. C) A patient care report cannot be revised or corrected after submission. D) If a report needs revision, the revision must be made within 12 hours.
Where can I find Chapter 6 documentation flashcards?
Study Chapter 6 Documentation flashcards from Bruce Wayne's Miami-dade class online, or in Brainscape's iPhone or Android app. ✓ Learn faster with spaced repetition. Chapter 6 Documentation Flashcards by Bruce Wayne | Brainscape
What elements are typically included in the patient care report?
There are seven elements (at a minimum) that we have identified as essential components to documenting a well written and complete narrative.Dispatch & Response Summary. ... Scene Summary. ... HPI/Physical Exam. ... Interventions. ... Status Change. ... Safety Summary. ... Disposition.
What is a patient care report in EMS?
Patient care report means a record of the response by each responding Emergency Medical Services Provider unit to each patient during an EMS Incident.
Under what circumstances can you legally release confidential patient information?
Mandatory disclosure of information Under the CMIA, medical information must be released when compelled: by court order. by a board, commission or administrative agency for purposes of adjudication. by a party to a legal action before a court, arbitration, or administrative agency, by subpoena or discovery request.
Which of the following components are needed to prove negligence EMT?
In order to establish negligence, you must be able to prove four “elements”: a duty, a breach of that duty, causation and damages.
Why is a patient care report important?
The primary purpose of the Patient Care Report (PCR) is to document all care and pertinent patient information as well as serving as a data collection tool. The documentation included on the PCR provides vital information, which is necessary for continued care at the hospital.
What are the reasons to collect data on a patient care report?
Collecting healthcare data generated across a variety of sources encourages efficient communication between doctors and patients, and increases the overall quality of patient care providing deeper insights into specific conditions.
Which of the following would not be included on a patient information form?
Which information item is not included on the patient information form that new patients are required to complete? (Response Feedback: Patient information forms usually do not contain medical histories; these are most often completed on separate forms.)
In which of the following situations is it permissible to release information from a patient's records?
More generally, HIPAA allows the release of information without the patient's authorization when, in the medical care providers' best judgment, it is in the patient's interest. Despite this language, medical care providers are very reluctant to release information unless it is clearly allowed by HIPAA.
Which of the following are some common features designed to protect the confidentiality of health information contained in patient medical records?
locks on medical records rooms.passwords to access computerized records.rules that prohibits employees from looking at records unless they have a need to know.all of the above.
What are the 4 rules of negligence?
A Guide to the 4 Elements of NegligenceA Duty of Care. A duty of care is essentially an obligation that one party has toward another party to exercise a reasonable level of care given the circumstances. ... A Breach of Duty. ... Causation. ... Damages.
Which of the following most accurately describes negligence quizlet?
Which of the following most accurately describes negligence? performance of care that does not meet the accepted standards.
What are the 4 elements needed to prove negligence?
The existence of a legal duty to the plaintiff; The defendant breached that duty; The plaintiff was injured; and, The defendant's breach of duty caused the injury.
How do you take care of a patient report?
Document the patient's history completely. Remember bystanders or those close to the patient can often provide valuable information about the patient....Check descriptions. ... Check (and recheck) spelling and grammar. ... Assess your chief complaint description. ... Review your impressions. ... Check the final details.
How do you write a patient report?
Summary: The format of a patient case report encompasses the following five sections: an abstract, an introduction and objective that contain a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion.
What is the acronym for the patient care report in its electronic format?
Page 1 of 5 The primary purpose of the Patient Care Report (PCR) is to document all care and pertinent patient information as well as serving as a data collection tool. Article 30, section 3053 of the Public Health Law requires all certified EMS agencies to submit PCR/ePCRs to the Department.
How do you write a patient care report for a narrative?
How to Write an Effective ePCR NarrativeBe concise but detailed. Be descriptive in explaining exactly what happened and include the decision-making process that led to the action. ... Present the facts in clear, objective language. ... Eliminate incorrect grammar and other avoidable mistakes. ... Be consistent and thorough.
As an EMT, the standards of emergency care are often partially based on: Select one: A. Patient care cannot be discredited based on poor documentation. B. EMTs are not liable for any actions that are accurately documented. C. It is difficult to prove actions were performed if they are not included on the report. D. Incomplete reports are common and accepted in EMS.
C. It is difficult to prove actions were performed if they are not included on the report.
During your monthly internal quality improvement (QI) meeting, you review several patient care reports (PCRs) with the staff of your EMS system. You identify the patient's name, age, and sex, and then discuss the treatment that was provided by the EMTs in the field. By taking this approach to the QI process, you: Select one: A. violated the patient's privacy because you should have discussed the information only with the EMTs involved. B. acted appropriately but must have each EMT sign a waiver stating that he or she will not discuss the cases with others. C. adequately safeguarded the patient's PHI because the cases were discussed internally. D. are in violation of HIPAA because you did not remove the PHI from the PCR beforehand.
D. are in violation of HIPAA because you did not remove the PHI from the PCR beforehand.
In which of the following circumstances can the EMT legally release confidential patient information? Select one: A. The family requests a copy for insurance purposes B. The patient is competent and signs a release form C. A media representative inquires about the patient D. A police officer requests a copy to place on file
B. The patient is competent and signs a release form
In which of the following situations does a legal duty to act clearly exist? Select one: A. The EMT hears of a cardiac arrest after his or her shift ends. B. A call is received 15 minutes prior to shift change. C. A bystander encounters a victim who is not breathing. D. The EMT witnesses a vehicle crash while off duty.
B. A call is received 15 minutes prior to shift change.
Maintaining the chain of evidence at the scene of a crime should include: Select one: A. quickly moving any weapons out of the patient's sight. B. making brief notes at the scene and then completing them later. C. not cutting through holes in clothing that were caused by weapons. D. placing the patient in a private area until the police arrive.
C. not cutting through holes in clothing that were caused by weapons.
Putrefaction is defined as: Select one: A. decomposition of the body's tissues. B. blood settling to the lowest point of the body. C. separation of the torso from the rest of the body. D. profound cyanosis to the trunk and face.
A. decomposition of the body's tissues.
The EMT's scope of practice within his or her local response area is defined by the: Select one: A. medical director. B. state EMS office. C. local health district. D. EMS supervisor.
A. medical director.
To help protect patients, EMS agencies are required to have __________. Select one: A. public forums with their medical director B. online access to patient records C. a privacy officer to answer questions D. an anonymous reporting system
C. a privacy officer to answer questions
When is forcible restraint permitted? Select one: A. Only if consent to restrain is given by a family member B. When the patient poses a significant threat to self or others C. Anytime that the EMT feels threatened D. Only if law enforcement personnel have witnessed threatening behavior
B. When the patient poses a significant threat to self or others
What are the standards of emergency care?
As an EMT, the standards of emergency care are often partially based on:#N#Select one:#N#A. the wishes of the general public.# N#B. a consensus among paramedic supervisors.#N#C. locally accepted protocols.#N#D. the priorities of the medical director.
Who requests a copy of insurance?
D. The family requests a copy for insurance purposes
What does an EMT hear after a shift ends?
B. The EMT hears of a cardiac arrest after his or her shift ends.
Who requests a copy of insurance?
A. The family requests a copy for insurance purposes
What does an EMT hear after shift ends?
A. The EMT hears of a cardiac arrest after his or her shift ends.
How to respond to a home of a 59 year old man who is unconscious; has slow, shallow breathing?
They further state that there is a DNR order for this patient, but they are unable to locate it. You should:#N#Select one:#N#A. begin treatment and contact medical control as needed. #N#B. honor the patient's wishes and withhold all treatment.#N#C. transport the patient without providing any treatment.#N#D. decide on further action once the DNR order is produced.
What should be included in maintaining the chain of evidence at the scene of a crime?
Maintaining the chain of evidence at the scene of a crime should include:#N#Select one:#N#A. quickly moving any weapons out of the patient's sight.#N#B. making brief notes at the scene and then completing them later.#N#C. not cutting through holes in clothing that were caused by weapons.#N#D. placing the patient in a private area until the police arrive.
Can patient care be discredited based on poor documentation?
A. Patient care cannot be discredited based on poor documentation.
What is the purpose of sharing information with EMS providers about patient outcome?
share information with the EMS providers about patient outcome for purposes of quality assurance and education.
Who can revise a report?
Only the person who wrote the original report can revise or correct it.
Can patient information be shared?
patient information shall not be shared with entities or persons not involved in the care of the patient.
Who is responsible for writing medical abbreviations?from ncbi.nlm.nih.gov
From the limited publications, it appears that physicians are responsible for writing the vast majority of medical abbreviations. In private practice, it is usually the physician who writes medical abbreviations, but in large teaching hospitals, the medical and surgical residents write the most medical abbreviations, since they are the ones tasked with the writing of orders. However, other healthcare professionals who also regularly write medical abbreviations include dietitians, nurses, occupational and physical therapists, and social workers, albeit not in great numbers.
Why is it important to have a uniform list of medical abbreviations?from ncbi.nlm.nih.gov
The Joint Commission has also recommended having a uniform and standardized list of symbols, codes, and abbreviations that can enhance communication and understanding among healthcare workers, leading to improved patient safety. Many healthcare workers have consistently reported that they have a great deal of difficulty interpreting medical abbreviations, even in their own hospital.
Why are medical abbreviations bad?from ncbi.nlm.nih.gov
One of the biggest problems leading to medical errors is the failure to communicate, and this is made worse with the use of medical abbreviations which can have multiple meanings. Further communication lapses are often the result of using medical abbreviations, especially when writing medication orders for junior staff. The staff responsible for reading, interpreting and processing the medication order may misconstrue the abbreviation or may not even recognize it, leading to an erroneous meaning. For example, one very commonly reported misinterpretation of dosing is the use of a decimal point after a dose. For example. 5.0 is often mistaken for 50 and, if the dot is not seen-this can result in ten times the dose. [3]
Why is it important to not use abbreviations in medical terms?from ncbi.nlm.nih.gov
It is important to ensure that the patient and the family can understand the information provided to them without having to guess. Often patients have difficulty understanding discharge instructions and this can affect their ability to look after themselves or follow instructions.
How to reduce medication errors?from ncbi.nlm.nih.gov
While medication errors have many causes, one of the ways to reduce these errors is by improving written communication, whether it be electronic or written . In 2004, the Joint Commision developed the "Do Not Use" list of medical abbreviations as part of the requirements for meeting the National Patient Safety Goal, which primarily addresses the effectiveness of communication between healthcare workers. The Joint Commission has also recommended that all healthcare institutions create a standard list of acronyms, abbreviations, and symbols that should not be used. However, despite the development of "Do Not Use" lists, compliance is not 100%.
What should a paramedic do before leaving the emergency department?from quizlet.com
If the paramedic is unable to complete his or her patient care report before departing the emergency department, he or she should: A) leave, at a minimum, the patient's name and age, but recognize that the physician will perform his or her own exam.
What is the National Medication Error Reporting Program?from ncbi.nlm.nih.gov
The National Medication Error Reporting program is run by the US pharmacopeia MedMarx. This program permit s subscribing healthcare institutions to report and track medication errors in a standard format. From 2004 through 2006, there were 643,151 medication errors reported to MedMarx from 682 facilities of which 4.7% (29,974) were attributed to use of medical abbreviations.