Chapter 6 Documentation: Vital Vocabulary Flashcards
A narrative writing method that allows the narrative to be broken down into logical sections similar to the steps of the patient assessment; components include chief complaint, history, assessment, treatment, transport, and exceptions.
CHARTE method
A system that assists dispatchers in selecting appropriate units to respond to a particular call for assistance and provides callers with vital instructions until the arrival of EMS crews.
emergency medical dispatch (EMD)
A false statement in written form that defames a person’s good name.
libel
A standard used by Medicare to determine whether a patient’s condition requires ambulance transport in a particular situation.
medical necessity
The mandatory clinical assessment standard information that must be documented on every emergency call as set by Medicare and Medicaid, and per the National Highway Traffic Safety Administration for the purpose of the national data system.
minimum data set
Information that is observable and measurable, such as a patient’s blood pressure.
objective information
A legal document used to record all patient care activities during an incident; a handwritten or electronic report that describes the nature of the patient’s injuries or illness at the scene and the treatment provided; also known as the prehospital care report.
patient care report (PCR)
Findings that warrant no medical care or intervention, but which show evidence of the thoroughness of the patient exam and history.
pertinent negatives
A false verbal statement that injures a person’s good name.
slander
A narrative writing method in which information is organized into four categories: Subjective information, Objective information, Assessment, and Plan (for treatment).
SOAP method
Information that is obtained from the patient, but which cannot be seen, such as the symptoms a patient describes.
subjective information
