documentation

Question 1

what are the 2 main jobs?

Answer 1

trauma and medical

Question 2

what is the first thing as a paramedic you document?

Answer 2

the primary survey.cat hem, ABCD, AVPU

Question 3

what is documented in the pain assessment?

Answer 3

onset, location, duration, characteristics, aggravating factors, radiating, time and severity.

Question 4

what do you include in the cardiovascular element?

Answer 4

any chest pain? color of patient, any diaphoresis (sweating) , describe pulse, ecg recordings, syncope (passing out), rashes? apyrexic (fever), high or low bp, heart rate and any obvious cardiac problems.

Question 5

what is included in the respiratory element?

Answer 5

shortness of breath? difficultly breathing? shortness of breath at rest or exercise? able to talk in full sentences? oxygen sats. any cough symptoms. resp rate. chest pain. haemoptysis- coughing blood up from the lungs?. good rise and fall.

Question 6

what is included in gastrointestinal documentation?

Answer 6

abdominal pain? diarrhea? vomiting or nausea? eating and drinking as normal? toilet as normal? bowel sounds. abdomen soft or hard?

Question 7

what would you include in the gynaecological element?

Answer 7

any chance of pregnancy? menstrual cycle normal?

Question 8

what is included in the neurological element?

Answer 8

consciousness? GCS out of 15. (eye, motor and verbal response). fits, faints, falls, paranesthesia (skin crawling), headaches, visual disturbance, light headache. FAST test. AVVV (balance/speech, vomiting, dizziness, vision impairment). oriented to time and place. no confusions, PEARL.

Question 9

what is included in the care plan element?

Answer 9

patient have capacity for assessment?
observations undertaken
findings
pt conveyed to normal/ emergency road conditions
handed over to the nurse at hospital with no additional concerns.