CH. 6 Documentation Flashcards
a narrative writing method allows the narrative to be broken down into logical sections similar to the steps of the EMS assessment; components include chief complaint, history, assessment, treatment, transport, and exceptions
CHARTE method
the law enacted in 1996 that provides for criminal sanctions as well as civil penalties for releasing patient’s protected health information in a way not authorized by the patient
HIPAA
making a false statement in written form that injures a person’s good name
libel
a standard used by medicare to determine whether a patient’s condition requires ambulance transport in a particular situation
medical necessity
the mandatory clinical assessment standard information that must be documented on every emergency call as set by Medicare and Medicaid, and per the National Highway Traffic Safety Administration (NHTSA) for the purpose of the national data system
minimum data set
information that you observe and that is measurable, such as the patient’s blood pressure
objective information
a written record of the incident that describes the nature of the patient’s injuries or illness at the scene and the treatment provided; also known as the prehospital care report
patient care report
findings that warrant no medical care or intervention, but which, by seeking them, show evidence of the thoroughness of the patient examination and history
pertinent negatives
verbally making a false statement that injures a person’s good name
slander
a narrative writing method in which information is organized into four categories, including subjective information, objective information, assessment, and treatment plan
SOAP method
information that is told to you but which cannot be seen, such as the symptoms a patient describes
subjective information
