101.16 Electronic Patient Care Reporting (week 4) Flashcards

1
Q

An accurate and complete electronic patient care report (ePCR) will be prepared for the following instances

A
  1. Pt is assessed
  2. Medical care is rendered
  3. A patient is transported
  4. A patient is pronounced dead on scene or is dead on arrival
  5. Patient is transferred from one medical facility to another
  6. When the person or persons for whom EMS was dispatched refused treatment and or transport.
    7.Canceled calls or dry runs
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2
Q

A “Canceled Call” is:

A

Any call in which WPBFD units are dispatched to an EMS call and canceled prior to any unit arriving.

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3
Q

When a “Canceled Call” occurs, an _____ will be completed with a disposition of “______ _______ ____ _______ __ ______”.

A

ePCR
“Canceled (Prior to Arrival at Scene)”

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4
Q

Any units which were canceled encounter by another unit on scene will not be responsible for preparing an _______ but will be carried on the _____ ___ ________ _____ ______.

A

ePCR
FIRST DUE ARRIVING UNIT’S report.

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5
Q

What is a “Dry Run”?

A

Any call in which WPBFD unit’s are dispatched to an EMS call and, after arriving on scene, no patient is found or the patient is unable to be located.

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6
Q

When a “Dry Run” occurs, the ______ ___ ________ ____ will complete the ePCR with a disposition of “___ _______ _____ (________ __ _____)”.

A

FIRST DUE ARRIVING UNIT
“No Patient Found (Canceled on Scene).

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7
Q

A Patient Release will be utilized whenever…

A

Whenever a competent patient has been advised of a medical need for evaluation and/or transport and refuses.

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8
Q

In general, all patients that WPBFD units respond to should either be…..

A

Transported or released and either turned over to a responsible official or party or, in some cases, to their own recognizance.

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9
Q

Only a _________ or an __________ ___________ can sign a release for a minor.

A

Guardian or an adult relative

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10
Q

A _______ _________ including the following list shall be submitted to the receiving hospital during a ________-___-_________ patient turnover prior to departure from hospital

A

Verbal report
Face-to-face

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11
Q

The verbal report that is submitted to the receiving hospital is to include:

A
  1. Patient information
  2. All interventions
  3. Any changes in patient status
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12
Q

A “________ __ _______ ____” _________ is required from the receiving facility on _____ transports.

A

“Transfer of Patient Care” signature
ALL

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13
Q

All ePCRs are required to be read and signed by both the “_______ ____ ________” for that event (also known as the “_______ ______”) and another “_____ ______”.

A

“Primary care provider”
“Report Author”
“Crew member”

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14
Q

It is preferred, but not required, that the other crew member signature be that of the ________ _________ if he/she is not the “_______ _____ ______” for that event.

A

Company officer
“Primary Care Provider”

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15
Q

EMT’s may complete and sign ____ and “___ ___” reports only.

A

BLS and “Dry Run”

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16
Q

If a Suppression unit arrives on scene and only has time to acquire basic vital signs before being relieved by a Transport unit, an ePCR…….

A

Will not need to be completed by the Suppression unit.

17
Q

If a Suppression unit arrives on scene and does either ALS interventions or the on scene time is greater than 5 minutes without a Transport unit, the suppression unit should……

A

Should start a report and transfer the report to the arriving Transport Unit.

18
Q

Units which arrive on medical scenes and perform suppression activities only will be responsible to complete what?

A

A NFIRS report only, as long as an ePCR is generated by a unit rendering medical care.

19
Q

Units traveling in tandem as a _____ ______ shall be considered a _______ unit and only _____ ePCR shall be required.

A

Task force
Single
One

20
Q

A narrative is to include information regarding the _______, ________, __________, and ______________ that are not provided elsewhere in the ePCR

A

Situation, background, assessment, and recommendations
(S.B.A.R. Format)

21
Q

In the incident of a _______ ________ ___________ with no injuries, a narrative describing the incident is _________, as well as what?

A

Motor vehicle accident
Required
As well as refusal signatures from patients (or pt representatives) who advise that they are not injured.

22
Q

Who will sign as a witness for patients at a motor vehicle scene who claim to have no injuries and refuse to be transferred?

A

Law enforcement or the Company Officer of the non-authoring unit if there is no law enforcement on scene.

23
Q

When might it be necessary to quote what a patient says?

A

When trying to best describe a chief complaint or to better explain something in the narrative.
Use prudent judgement

24
Q

When dealing with patients with multiple medications, pleas list the top ____ (or _____) which are __________ to patients ________.

A

Top 5 (or fewer)
Pertinent to patients history

25
Q

All calls with a disposition of “Dead on Arrival” (Code ___) require what?

A

Code 7
Require a complete ePCR with a complete narrative to be generated.

26
Q

What is also required with a Code 7 pt, except in the case of obvious _________ ______ or when ______________ is evident.

A

An ECG strip
Except obvious Traumatic Death or when Decomposition is evident.

27
Q

All reports, at a minimum, shall be completed prior to what?

A

Going off duty

28
Q

A complete medical report shall be available within how many hours of the incident?

A

24 hours

29
Q

Only ___________ abbreviations are to be used for documentation

A

Official