CFRD Chapter 5-Documentation

Question 1

PCR (“D” Documenter/Defib)…where is PART ONE?

Answer 1

FORWARDED to the Officer of MEDICAL AFFAIRS ………..BY END OF EACH TOUR

Question 2

Part TWO?

Answer 2

Research Copy and retained at QUARTERS and MUST be secured by the COMPANY OFFICER in company files at all times

Question 3

PART THREE?

Answer 3

HOSPITAL PATIENT RECORD COPY….
-IF COMPLETED…GIVEN TO EMS UNIT OPERATING AT THE SCENE

**if NOT given to EMS unit,,,,forwarded with PART ONE(ORIGINAL) TO OMA

Question 4

A——PCR for each patient treated ?

Answer 4

SEPARATE

Question 5

Is a PCR required if CFRD unit is on scene (10-84) AND NOT PATIENT CONTACT IS MADE?

Answer 5

NO—ONLY IF PATIENT CONTACT IS MADE

Question 6

PCR MUST be completed when patient care is provided by a CFRD certified member, regardless of type and /or unit assignment….situations requiring PCR?

Answer 6

• AED
• CPR
• O2
• stabilizing neck
• immobilizing patient
• providing ANY OTHER PATIENT CARE (asking question…“what’s wrong?” PCR)

only DOCUMENT CARE OF CFRD COMPANY, not EMS unit

Question 7

Who is responsible for accuracy , completeness and legibility of the PCR?

Answer 7

OFFICER

-but he ASSIGNS MEMBER to complete PCR

Question 8

At any scene not requiring a PCR or a NYFIRS report, company officer has option of completing ?

Answer 8

UNUSUAL OCCURRENCE REPORT

Question 9

When a CFRD company APPLIES and TURNS ON AED DURING CARDIAC ARREST RESUSCITATION ATTEMP (10-37 Code 2), the ORIGINAL PCR (PART ONE) shall be IMMEDIATELY FAXED AND FORWARDED TO ?

Answer 9

OFFICE OF MEDICAL AFFAIRS on return to quarters

Question 10

What should be turned into CFRD Depot?

Answer 10

COPY of the original PCR (PART ONE) ALONG WITH AED MODULE upon completion of assignment

• This MODULE (NOT AED ) will be exchanged for a blank one and the CFRD DEPOT WILL IMMEDIATELY FORWARD THE MODULE AND PCR COPY directly to OMA
• serial number of module documented on PCR *

Question 11

IF A CFRD COMPANY’S AED is NOT applied to a patient during a RESPONSE TO A CARDIAC ARREST the details, of the incident and what prevented the application of the CoMpany’s AED shall be ?

Answer 11

INDICATED IN COMMENTS SECTION OF PCR

Question 12

PCR time at ALL TIMES written in ?

Answer 12

MILITARY TIME (4 DIGITS )

Question 13

PCR–Members shall use only ONE character per box…

Answer 13

NO APOSTROPHES, DASHES, PERIODS, SLASHES

Question 14

HOW to make correction on PCR ?

Answer 14

SINGLE line through word(s) to be omitted or corrected and write the accurate info above the words to be corrected

-press firmly and DARKEN in all circles completely

Question 15

AGENCY CODE?

Answer 15

FD code “0167”

Question 16

Run number ?

Answer 16

4 digit alarm box number

Question 17

Patients name?

Answer 17

fill in as many letters as possible

if unable to obtain name: “ UNKNOWN MALE”

-neve use Jane Doe/John Doe

Question 18

Age of Patient ?

Answer 18

ENTER AGE , even if date of birth is documented …if unknown, approximate age

less than a year: (H-hours, D-days, w-weeks, M=months)
6 day old infant—06D

Question 19

T or F…enter social security number?

Answer 19

TRUE —if unattainable, leave blank

Question 20

Chief complaint?

Answer 20

Enter in patients OWN WORDS, “my chest hurts”

if patient is UNRESPONSIVE, “PATIENT UNRESPONSIVE

-If other than patient (mother ) gives info, write, “mother states, my baby is sick”

Question 21

T or F …A MINIMUM of ONE SET OF VITALS are required for ALL ADULT PATIENTS except for CARDIAC ARRESTS AND DOAS..

Answer 21

for Cardiac Arrest and DOA , respiratory rate and pulse are documented as “0”….BP not taken and space is left blank

Question 22

Critical ?

Answer 22

patient is either RECEIVING CPR, in RESPIRATORY ARREST or requiring and receiving life sustaining ventilatory /circulatory support

Question 23

Unstable?

Answer 23

patient is unstable, sever upper airway difficulties, serious chest trauma, decompensated shock, rising intracranial pressure, uncontrollable external hemorrhage, penetrating injury to head , neck, chest, abdomen

Question 24

Potentially unstable?

Answer 24

early signs of compensated shock, kinematics or injuries suggest ‘HIDDEN INJURY”, MAJOR INJURY , SEVER CHEST PAIN…especially with a systolic BP of less than 100 mmHG, inability to move ANY PART OF YOUR BODY

Question 25

STABLE?

Answer 25

minor illness, minor isolated injury, uncomplicated extremity injuries, cannot be categorized as critical, unstable, potentially unstable

Question 26

CREW?

Answer 26

members shall document the names and certification numbers of the CFR-D certified members who responded to the call AND PROVIDE PATIENT CARE

• name of member in charge (OFFICER) in FIRST BOX
• continue with member name in 2nd box
• if there are more than 4 CFRD certified members, use COMMENTS SECTION

**if the CHAUFFEUR does not provide patient care, DO NOT ENTER his name on PCR

**circle the NAME OF MEMBER COMPLETING PCR **