Chapter 6 Vocab Flashcards
patient care report (PCR)
legal document used to record all patient care activities during an incident
objective info
measurable signs that are observed and recorded
subjective info
information that a patient tells you but cannot be seen
medical necessity
standard used by Medicare to determine if a patient needs transport
national emergency medical services information system (NEMSIS)
collects data to improve patient care, indicates equipment needs, and defines a standard of care across the nation
minimum set
the clinical assessment standard info that must be documented on every call
- run data & patient data
emergency medical dispatch (EMD)
dispatch that can provide simple directions for medical care or medication administration over the phone
chronological order charting
explaining the call from start to finish and paints the clearest picture to provide the best legal defense
SOAP method
subjective info, objective info, assessment, and plan (treatment)
CHARTE method
chief complaint, history, assessment, treatment, transport, and exceptions
body systems approach
assessment of each patient’s body systems, but may be too time consuming
pertinent negatives
a record of negative findings through an assessment that indicate that care is not needed
