Communication and Documentation Flashcards
1
Q
What are the guidelines for the narrative component of the PCR?
A
-include both objective and pertinent subjectives
-only state the obvious
-include pertinent negatives
-avoid radio codes and abbreviations
-write legibly and proper spelling
-use medical terms correctly
if it’s not written down, you didn’t do it!
2
Q
What do you include in a radio medical report?
A
- unit ID and level of provider
- estimate TOA
- patients age and sex
- chief complaint
- brief history of present issue
- major pmhx
- mental status
- baseline vitals
- findings on physical exam
- care given
- response to care
- if called medical direction- include
3
Q
What to include in patient handoff report?
A
-patients name
-chief complaint
-any history not given previously
-additional treatment enroute
-additional vitals
