Chapter 4

Question 1

Minimum data set

Answer 1

The set of data the DOT recommends including on all PCR’s.
Patient information, chief complaint, level of responsiveness, blood pressure for patient greater than 3, skin perfusion less than 6, skin color temp and condition, pulse rate

Administrative information, time the incident was reported, time the unit was notified, time of arrival at patient, time the unit left the scene l, time the unit arrived at its destination, time of transfer of care

Question 2

Pertinent negatives

Answer 2

Signs or symptoms that might be expected, based on the chief complaint, but that the patient denies having

Question 3

Pre hospital care report

PCR

Answer 3

Form of written or electrical, generated records that helps to ensure that the patient receives the best most appropriate care at the facility he is transported.

Question 4

Triage tag

Answer 4

Basic info, such as church complaint, vital signs, and treatment provided is recorded. Information can be used later to complete the PCR

Question 5

S. O. A. P.

Answer 5

S- subjective. / refers to the info the patient must tell you. Info or symptoms you can not see or feel in physical exam
O- objective. / info that you identify, through inspection palpation, and auscultation.
A- assessment. / refers to field assignment, the general idea you form about the patients condition based on information you have collected.
P- plan. / refers to the plan of action and the emergency care provided to the patient.

Question 6

C. H. A. R. T.

Answer 6

C- chief complaint / refers to the main complaint of the patient.
H- history. / refers to the history of the patient ( including the SAMPLE history )
A- assessment. / findings gathered in the primary assessment, detailed physical exam, and ongoing assessment.
R- Rx. / refers to treatment that was provided to the patient.
T- transport. / any change in the patients condition en rout and the type of transport.

Question 7

C. H. E. A. T. E. D.

Answer 7

C- chief complaint / reason why EMS was called
H- history / the history of the patient, including sample history.
E- exam / info that is found in the physical examination of the patient
A- assessment/ field impression you derive by processing the history and physical exam findings and determining a condition the patient may be suffering from.
T- treatment / the treatment that was provided to the patient
E- evaluation / info that is found during the ongoing assessment and any identified improvement of deterioration of the patient condition
D- disposition / transfer of patient care at the medical facility or to another health care provider.