1090 - Patient Care Report

Question 1

General

All patient care reports are required to be completed by the _______ ____ _______.

Answer 1

end of shift

pg. 1

Question 2

All chief officers must review ________ status daily to ensure that all reports have been completed on time.

Answer 2

CAD

pg. 1

Question 3

General

The Rescue Officer will provide the ________ EMS field copy to the hospital.

Answer 3

white

pg. 1

Question 4

General

All EMS field copies must be __________________ after completion of the electronic PCR.

Answer 4

shredded

pg. 1

Question 5

Emergency Pro reporting system

The Emergency Pro report system is designed to recognize the report writer as the _________ __________ member.

Answer 5

lead crew

pg. 1

Question 6

Explanation of disposition codes:

Stand By

Answer 6

• Non-transporting rescue/non-primary suppression unit on a cardiac arrest, Hostage situations, secondary units for extrication, MCI’s or any additional manpower requests.

pg. 1

Question 7

Explanation of disposition codes

Citizen Assist

Answer 7

• Used for assist a citizen without a medical complaint

pg. 1

Question 8

Explanation of disposition codes

False Call

Answer 8

• Any false call, no patient found

pg. 1

Question 9

Explanation of disposition codes

False Call

Answer 9

• Any false call, no patient found

pg. 1

Question 10

Explanation of disposition codes

DOA

Answer 10

• Any obvious death

pg. 1

Question 11

Explanation of disposition codes

Pronouncement of Death

Answer 11

• Any patient that is pronounced on scene (e.g. MVA, GSW)

pg. 1

Question 12

Explanation of disposition codes

Evaluation Only

Answer 12

• Patient evaluation only

pg. 1

Question 13

Explanation of disposition codes

Law Enforcement

Answer 13

• Patient evaluated by JFRD but transported by Law Enforcement

pg. 1

Question 14

Explanation of disposition codes

Refused Evaluation

Answer 14

• Anytime a patient refuses an assessment

pg. 1

Question 15

Explanation of disposition codes

Refused Treatment/Transport

Answer 15

• The patient refused treatment and/or transport after evaluation

Question 16

Explanation of disposition codes

Treated and Refused Transport

Answer 16

• Patient treated on scene and refused transport

pg. 1

Question 17

Explanation of disposition codes

Transfer to another EMS agency

Answer 17

• Transferred to ATU

pg. 2

Question 18

Explanation of disposition codes

Unit Assist

Answer 18

• Unit assist will be used every time a suppression unit arrives on scene at the same time or has the same patient contact time as the Rescue unit.

Question 19

Explanation of disposition codes

Treated and Transferred Care Within Agency

Answer 19

• Treated and Transferred Care within Agency MUST be used when the Suppression apparatus arrives on scene first and provides care prior to the arrival of the Rescue unit. This documentation must include all information from patient contact time to the transfer of care to the Rescue unit.

pg. 2

Question 20

Record q __ min. if the patient is unstable or q __ min. if the patient is stable. Minimum of 2 required for all txported patients (1 at or near pt. contact and 1 near arrival at hospital).

Answer 20

5, 15

pg. 2

Question 21

The paper signature form must be delivered to the Rescue District/Battalion Chief who will then deliver to the ___________ _______________ ___________ during their next visit to Headquarters.

Answer 21

Quality Improvement Officer

pg. 2

Question 22

The ONLY approved JFRD format for PCR Narrative:

Answer 22

• CC: (Chief Complaint)
• HPI: (History of Present Illness)
• PE: (Physical Exam)
• TX: (Treatment)

Question 23

Note: This additional section will be used for
any unsual circumstances that occur during the entire duration of the incident. (pt. contact delays, pt./family issues,)
true or false?

Answer 23

true

pg. 3

Question 24

Assess and document the competency of the patient. For EMS purposes, a competent patient shall be defined as one who meets ALL of the following criteria: (3)

Answer 24

• Is greater than or equal to 18 yrs. of age or court certified emancipated minor.
• Awake, alert and fully oriented to person, place, time and event.
• Is not intoxicated and under the influence of drugs, or otherwise incapable of providing informed consent.

pg. 4

Question 25

Care may be refused for a minor (less than 18 yrs. of age) ONLY if ALL of the following are met: (3)

Answer 25

• The patient exhibits no historical or physical findings of potentially life, limb, organ threatening injury or illness.
• The patient is not intoxicated and has no alterations in mental status, level of consciousness or vital signs.
• The responsible parent/legal gaurdian is competent and present.

pg. 4

Question 26

If the patient is NOT competent to refuse transport: (2)

Answer 26

• Explain to the patient (or parent/legal gaurdian), the need for transport
• Reassure the patient that no harm will result from transport but complications, up to and including death, may result from a delay in treatment.

pg. 5

Question 27

If the patient continues to refuse care and satisfies FS 401.455 “Emergency examination of incapacitated persons.” (2)

Answer 27

• Enlist the aid of law enforcement personnel for patient and crew safety.
• Proceed with transport of the patient

pg. 5

Question 28

If the patient (or parent/legal gaurdian) is competent to refuse transport, emphasize: (4)

Answer 28

• The need for treatment/transportation
• The risks of refusal of care (including death and disability)
• The willingness of EMS to transport the patient
• The patient or parent/legal gaurdian should call 911 again if there is any changes in their condition

pg. 5

Question 29

No one else can sign for a legally competent adult patient (e.g., spouses, relatives and friends, etc.)

true or false?

Answer 29

true

pg. 5

Question 30

When documenting a competent witness’s info include: Printed name, signature, and phone number number.

Appropriate witnesses (in order of preference)

Answer 30

• Spouses, relatives, law enforcement, friends, other fire/rescue personnel.

pg. 5

Question 31

The documented refusal is only valid with an appropriate witness signature.

true or false?

Answer 31

true

pg. 5

Question 32

The JFRD officer who is documenting and executing the legal refusal CAN sign as the witness.

true or false?

Answer 32

false (CAN NOT)

pg. 5

Question 33

Signed refusals on the EMS field copy (laptop failure only) will be completed and filed at the station.

true or false?

Answer 33

true

pg. 5

Question 34

Once a year, completed paper refusals will be forwarded to the __________ _____________ ________.

Answer 34

Quality Improvement Office

pg. 6