1090 - Patient Care Report Flashcards
General
All patient care reports are required to be completed by the _______ ____ _______.
end of shift
pg. 1
All chief officers must review ________ status daily to ensure that all reports have been completed on time.
CAD
pg. 1
General
The Rescue Officer will provide the ________ EMS field copy to the hospital.
white
pg. 1
General
All EMS field copies must be __________________ after completion of the electronic PCR.
shredded
pg. 1
Emergency Pro reporting system
The Emergency Pro report system is designed to recognize the report writer as the _________ __________ member.
lead crew
pg. 1
Explanation of disposition codes:
Stand By
• 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
Explanation of disposition codes
Citizen Assist
• Used for assist a citizen without a medical complaint
pg. 1
Explanation of disposition codes
False Call
• Any false call, no patient found
pg. 1
Explanation of disposition codes
False Call
• Any false call, no patient found
pg. 1
Explanation of disposition codes
DOA
• Any obvious death
pg. 1
Explanation of disposition codes
Pronouncement of Death
• Any patient that is pronounced on scene (e.g. MVA, GSW)
pg. 1
Explanation of disposition codes
Evaluation Only
• Patient evaluation only
pg. 1
Explanation of disposition codes
Law Enforcement
• Patient evaluated by JFRD but transported by Law Enforcement
pg. 1
Explanation of disposition codes
Refused Evaluation
• Anytime a patient refuses an assessment
pg. 1
Explanation of disposition codes
Refused Treatment/Transport
• The patient refused treatment and/or transport after evaluation
Explanation of disposition codes
Treated and Refused Transport
• Patient treated on scene and refused transport
pg. 1
Explanation of disposition codes
Transfer to another EMS agency
• Transferred to ATU
pg. 2
Explanation of disposition codes
Unit Assist
• 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.
Explanation of disposition codes
Treated and Transferred Care Within Agency
• 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
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).
5, 15
pg. 2
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.
Quality Improvement Officer
pg. 2
The ONLY approved JFRD format for PCR Narrative:
- CC: (Chief Complaint)
- HPI: (History of Present Illness)
- PE: (Physical Exam)
- TX: (Treatment)
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?
true
pg. 3
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)
- 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
Care may be refused for a minor (less than 18 yrs. of age) ONLY if ALL of the following are met: (3)
- 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
If the patient is NOT competent to refuse transport: (2)
- 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
If the patient continues to refuse care and satisfies FS 401.455 “Emergency examination of incapacitated persons.” (2)
- Enlist the aid of law enforcement personnel for patient and crew safety.
- Proceed with transport of the patient
pg. 5
If the patient (or parent/legal gaurdian) is competent to refuse transport, emphasize: (4)
- 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
No one else can sign for a legally competent adult patient (e.g., spouses, relatives and friends, etc.)
true or false?
true
pg. 5
When documenting a competent witness’s info include: Printed name, signature, and phone number number.
Appropriate witnesses (in order of preference)
• Spouses, relatives, law enforcement, friends, other fire/rescue personnel.
pg. 5
The documented refusal is only valid with an appropriate witness signature.
true or false?
true
pg. 5
The JFRD officer who is documenting and executing the legal refusal CAN sign as the witness.
true or false?
false (CAN NOT)
pg. 5
Signed refusals on the EMS field copy (laptop failure only) will be completed and filed at the station.
true or false?
true
pg. 5
Once a year, completed paper refusals will be forwarded to the __________ _____________ ________.
Quality Improvement Office
pg. 6
