Chapter 19 - Documentation

Question 1

Health Insurance Portability and Accountability Act (HIPPA)

Answer 1

Rules governing the protection of a patient’s identifiable information.

Question 2

Medical Terminology

Answer 2

Greek and latin bases words (typically) 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 not to be present hat support a working diagnosis.

Question 5

Pertinent Positive

Answer 5

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

Question 6

Prefix

Answer 6

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

Question 7

Prehospital Care Report (PCR)

Answer 7

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

Question 8

Root Word

Answer 8

In medical terminology, the part of the word that gives the primary meaning.

Question 9

Scope of Practice

Answer 9

The set of procedures a paramedic is allowed and expected to perform.

Question 10

Subjective Information

Answer 10

Information told to the paramedic

Question 11

Suffix

Answer 11

Added to the end of a root word to change the meaning. Usually identifies the condition of the root word

Question 12

Trip Audit

Answer 12

The review of a PCR written by a paramedic by a peer or third party.