Ch8 Key Terms - Communication and Documentation

Question 1

A process whereby information is transmitted from one person to another.

Answer 1

Communication

Question 2

Notes written by OEC technicians at the scene of a patient rescue; may include a timeline, vital signs, witnesses’ names, and other pertinent information.

Answer 2

Field care notes

Question 3

An oral or written report given at the transfer of a patient from one provider to another.

Answer 3

Handoff report

Question 4

A group of personnel, usually including representation of management at a resort, who evaluate and document any accident that needs further legal documentation.

Answer 4

Incident investigation (II) team

Question 5

A form provided by the National Ski Areas Association, a ski resort, or an insurance carrier, used by OEC technicians to document an incident; the forms include patient information and the circumstances leading to injury.

Answer 5

Incident report form

Question 6

A report documenting a patient’s complaints and past medical history, plus a chronological (timeline) account of the examination and treatment of the patient, including vital signs. This is a legal document.

Answer 6

Patient report (PCR)

Question 7

The practice of maintaining the security and confidentiality of patient records. It includes the conversational discretion of health care providers and the security of all medical records.

Answer 7

Patient privacy