chap 4 Flashcards
what is objective information
info based on observable signs like clinical facts
subjective information
info based on opinions expressed by the patient or others of subjective feelings like clinical symptoms
documentation provides
a tangible and legal record of the event
four main reasons for charting patient care
demonstrate continuity of patient care
create legal record
assist in financial record for patient and reimbursement of the department
how long are medical records kept
10 years for adults and varies widely for minors
narrative facilitates what
continuity of care
elements of properly written ems document
accurate and complete
legible
timely
unaltered
free of non professional info
subjective info in the narrative
entered in quotes of the patients words
SAMLE
signs, allergies, meds, last intake, events leading up to
SOAP
subjective data, objective data, assessment data, plan for care
CHART
chief complaint, history, assessment, RX, transport
CHEATED
chief complaint, history, exam, assessment, treatment, eval, disposition
primary body system approach
examination of one body system based on chief complaint,
chronological approach
noting initial findings and a time line of assessments and interventions/ treatments done
patient management/medical narrative approach
organize and report the complete patient management plan
patient refusal
document everything from arrival to departure
mass casualty events
comprehensive documentation may be postponed and should follow local protocols
document revision
make correction as soon as possible
note purpose of revision and reason why
date and time
made by original author
