chapter 19 - documentation

Question 1

health insurance portability and accountability act

Answer 1

HIPPA - rules governing the protection of a patients identifiable information

Question 2

medical terminology

Answer 2

greek and latin based words that function as a common language for the medical community

Question 3

objective information

Answer 3

verifiable findings, such as information seen, felt, or heard by the paramedic

Question 4

pertinent negative

Answer 4

in a patient assessment, the signs and symptoms found to be present that support a working diagnosis

Question 5

prefix

Answer 5

added to the beginning of a root word to alter the meaning. Usually identifies location or frequency

Question 6

prehospital care report

Answer 6

PCR - the report written by the paramedic after the call has been completed. The report becomes part of the patient’s permanent record

Question 7

root word

Answer 7

in medical terminology, the part of the word that gives the primary meaning

Question 8

scope of practice

Answer 8

the set of procedures a paramedic is allowed and expected to perform

Question 9

subjective information

Answer 9

information told to the paramedic

Question 10

suffix

Answer 10

added to the end of a root word to change the meaning. usually identifies the condition of the root word.

Question 11

trip audit

Answer 11

the review of a PCR written by a paramedic by a peer or a third party