Chapter 4 Documentation

Question 1

what is the most common type of record that is prepared in a pre-hospital setting?

Answer 1

Pre-hospital care report (PCR)

Question 2

What is the function of a pre-hospital care report (PCR).

Answer 2

helps with:
Continuity of care
Administrative uses

Question 3

What is Continuity of care

Answer 3

Refers to the coordination of care between heath care personnel and the patient during the course of their illness or injury.

EMT’s start this process by giving a baseline against which that patient’s improvement or deterioration can be measured.

Question 4

What is the Administrative Uses of a (PCR)

Answer 4

(PCR) become apart of a patients permanent hospital record for billing & insurance and it may be used for statistical research.

Question 5

When does a (PCR) become a Legal Document

Answer 5

a run that EMT’S is involved in can be a crime scene or end up a civil lawsuits. EMT will need to refer to the run sheet while in court.

Question 6

How is a (PCR) use in educational and research uses?

Answer 6

scientists and researchers use the date on PCR to evaluate positive/negative effects during different stages of patient contact. Administrators look for was to make care more efficient and improve training programs.

Question 7

How does (PCR) help with evaluation and continuous quality improvement?

Answer 7

Medical oversight committees use data to ensure that EMTs are adhering to protocols and standard of care. Data in PCR show area’s that need improvement for training.

Question 8

What are some other names for a PCR?

Answer 8

run sheet or trip sheet

Question 9

what is the most traditional format for a PCR?

Answer 9

written report

Question 10

What is an alternative to a written PCR?

Answer 10

computer direct data entry report

Question 11

What are the two basic rules of a PCR?

Answer 11

1) If it was written down, it wasn’t done

2) If it wasn’t done, don’t write it down

Question 12

What is a minimum data set?

Answer 12

it is data that is required on a PCR by the department of transportation (DOT).

Question 13

What is included in Patient Information in a minimum data set?

Answer 13

Chief complaint
Level of responsiveness (AVPU) -mental status
Blood pressure
skin perfusion
skin color, temperature, & condition
pulse rate
respiratory rate & effort
patient demographics (age, sex, race, weight)

Question 14

What is included in Administrative Information (run data)

Answer 14

Time incident was reported
Time unit was notified
Time of arrival at the patient
Time the unit left the scene
Time the unit arrived at its destination (hospital etc)
Time of transfer of care
Also: 
EMS Unit number
Name of crew & cert levels
dispatched address

Question 15

What is the third major division of the PCR?

Answer 15

Vital Signs

Question 16

What information should be included in the Vital Signs?

Answer 16

Ideally 2 sets of vitals

patients position when taken
time taken

Question 17

What is the Patient Narrative on the PCR?

Answer 17

this section give detailed information about the patient and what their problem is

Question 18

The narrative contains what?

Answer 18

1) The patients chief complaint (in patients words)

2) The patients history or a description of the mechanism of injury - when/how

Question 19

What is objective information?

Answer 19

Information that is measurable and verifiable.

i.e. pulse, color of skin etc

Question 20

What is subjective information?

Answer 20

information based on an individuals perceptions or interpretations.
i.e. the patient seems to be in pain

The information should be pertinent; it should relate to the medical circumstances.

Question 21

What are Pertinent Negatives

Answer 21

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

i.e denial of pain after an automobile accident

Question 22

What is the Treatment section of the PCR contain?

Answer 22

the chronological treatment that was provided to the patient

Question 23

Confidentiality of (PCR)

Answer 23

Keep patient information private

Question 24

Distribution of (PCR)

Answer 24

Follow local and state rules
You can give information to health care provider that is apart of continuity of care process.
copy of PCR given to patient

Question 25

Refusal of treatment of (PCR)

Answer 25

Be sure to document everything regarding refusal

Question 26

Falsification of (PCR)

Answer 26

when there is an error on PCR it must be highlighted.

document exactly what did or didn’t happen.

EMT can lose license and face criminal charges for falsify info on PCR

Question 27

How do you correct errors on a PCR?

Answer 27

in written form - draw a single horizontal line through the error, initial it, and write the correct information next to it.

if found after submitted to same as above also add date and time and do it in different color ink.

electronically: print a copy of report and do the steps above.

Question 28

in what situation would a standard PCR not be appropriate?

Answer 28

transfer-of-care
Multiple-Casualty Incident
suspected abuse
exposure to an infectious diseases
other situation that an EMT feels needs to be reported to an agency

Question 29

When would an EMT use an abbreviated transfer-of care form or a drop report?

Answer 29

In situations where the EMT has to return immediately to the field to answer another call or when there is no way to print a hard copy.

Question 30

What is a triage tag?

Answer 30

It is a tag used during a multiple causality situation that is placed on a patient with their basic information.

Question 31

What are 3 alternative mnemonic methods use to organize information on a PCR?

Answer 31

SOAP
CHART
CHEATED

Question 32

What does Soap stand for?

Answer 32

S - subjective - info told to you
O- objective - info from doing inspection, palpation, auscultation
A- assessment - field assessment
P-plan- action & emergency care plan

Question 33

What does Chart stand for?

Answer 33

C-chief complaint - the problem
H-history - patients
A- assessment - field exam
R- RX - treatment 
T- transport- any change in the patient