CFRD Chapter 5-Documentation Flashcards
PCR (“D” Documenter/Defib)…where is PART ONE?
FORWARDED to the Officer of MEDICAL AFFAIRS ………..BY END OF EACH TOUR
Part TWO?
Research Copy and retained at QUARTERS and MUST be secured by the COMPANY OFFICER in company files at all times
PART THREE?
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
A——PCR for each patient treated ?
SEPARATE
Is a PCR required if CFRD unit is on scene (10-84) AND NOT PATIENT CONTACT IS MADE?
NO—ONLY IF PATIENT CONTACT IS MADE
PCR MUST be completed when patient care is provided by a CFRD certified member, regardless of type and /or unit assignment….situations requiring PCR?
- 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
Who is responsible for accuracy , completeness and legibility of the PCR?
OFFICER
-but he ASSIGNS MEMBER to complete PCR
At any scene not requiring a PCR or a NYFIRS report, company officer has option of completing ?
UNUSUAL OCCURRENCE REPORT
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 ?
OFFICE OF MEDICAL AFFAIRS on return to quarters
What should be turned into CFRD Depot?
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 *
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 ?
INDICATED IN COMMENTS SECTION OF PCR
PCR time at ALL TIMES written in ?
MILITARY TIME (4 DIGITS )
PCR–Members shall use only ONE character per box…
NO APOSTROPHES, DASHES, PERIODS, SLASHES
HOW to make correction on PCR ?
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
AGENCY CODE?
FD code “0167”
Run number ?
4 digit alarm box number
Patients name?
fill in as many letters as possible
if unable to obtain name: “ UNKNOWN MALE”
-neve use Jane Doe/John Doe
Age of Patient ?
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
T or F…enter social security number?
TRUE —if unattainable, leave blank
Chief complaint?
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”
T or F …A MINIMUM of ONE SET OF VITALS are required for ALL ADULT PATIENTS except for CARDIAC ARRESTS AND DOAS..
for Cardiac Arrest and DOA , respiratory rate and pulse are documented as “0”….BP not taken and space is left blank
Critical ?
patient is either RECEIVING CPR, in RESPIRATORY ARREST or requiring and receiving life sustaining ventilatory /circulatory support
Unstable?
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
Potentially unstable?
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
