CHAPTER 6: DOCUMENTATION

Question 1

SUBJECTIVE VS. OBJECTIVE INFORMATION

Answer 1

SUBJECTIVE: INFO TOLD TO YOU BUT CAN’T BE SEEN (NAUSEA, PAIN)
OBJECTIVE: MEASURABLE SIGNS (HR, BP)

Question 2

PURPOSES OF DOCUMENTATION (4)

Answer 2

CONTINUITY OF CARE
MINIMUM REQUIREMENTS AND BILLING
EMS RESEARCH
INCIDENT REVIEW AND QUALITY ASSURANCE

Question 3

SOAP

Answer 3

SUBJECTIVE INFO
OBJECTIVE INFO
ASSESSMENT
PLAN FOR TREATMENT

Question 4

DCHARTE

Answer 4

CHEIF COMPLAINT
HISTORY
ASSESSMENT
TREATMENT
TRANSPORT
EXCEPTIONS

Question 5

PERTINENT NEGATIVES

Answer 5

RECORD OF SOMETHING YOU DIDNT FIND (NO LOC, NO NAUSEA/VOMITING)

Question 6

DOCUMENTATION OF INCIDENT TIMES

Answer 6

TIME OF:
CALL
DISPATCH
ARRIVAL AT SCENE
PATIENT CONTACT
MEDICATION ADMINISTRATION
MEDICAL PROCEDURE
DEPARTURE FROM SCENE
ARRIVAL AT MEDICAL FACILITY
TRANSFER OF CARE
BACK IN SERVICE

Question 7

HOW TO MAKE AMMENDMENT TO REPORT

Answer 7

MUST KEEP ORIGINAL
TIMESTAMP WHEN ADDENDUM WAS MADE AND BY WHO