Documentation Flashcards
What is the purpose of documentation in patient care reports (PCR)?
To provide a clear account of the emergency, track the patient through the medical system, and facilitate hospital follow-up
Documentation is crucial for legal, medical, and billing purposes.
What does the narrative portion of the PCR allow you to do?
It allows you to ‘tell the story’ of the emergency call
This narrative must be neat and legible.
What are the six generally accepted sections of a PCR?
- On arrival
- Chief complaint
- History of chief complaint
- Past medical history
- On examination
- Treatment
These sections provide a structured approach to documenting patient encounters.
What should be included in the ‘Chief Complaint’ section of a PCR?
The reason for the call, using the patient’s own words, and should not be a diagnosis
Examples include ‘chest pain’ or ‘unresponsive post-MVA.’
How should the ‘History of Chief Complaint’ be documented?
It should describe when the problem started, what the patient was doing, and include pertinent positive and negative findings
The OPQRST method can be used to describe pain.
What does the ‘Past Medical History’ section of a PCR include?
- Previous medical problems
- Diagnosed diseases
- Surgical procedures
- Lifestyle factors like smoking or drug use
This section can include information dating back decades.
What type of information is recorded in the ‘On Examination’ section?
A well-organized report of physical exam findings, organized by anatomical areas or body systems
This section is crucial for identifying trauma and other conditions.
What is the difference between the anatomical and systems approach in the ‘On Examination’ section?
Anatomical is a scenario survey of body parts, while systems describe specific signs and symptoms of each system
Different approaches can be effective depending on the patient’s condition.
What details should be recorded in the ‘Treatment’ section?
- Medical treatments performed
- Oxygen flows and devices used
- IV details including gauge and site
- Transport details
Specificity is key for clarity and follow-up.
What is essential to do after completing a PCR?
Always sign your PCR
If a continuation form is used, sign both pages.
True or False: If you didn’t document it clearly, it didn’t happen.
True
Clear documentation is crucial in emergency medical services.
Fill in the blank: The acceptable format for PCR includes a description of the scene, your initial impression of the patient, and any other _______.
pertinent info
This includes road conditions, time of day, and bystanders.
What is the significance of using the patient’s own words in the PCR?
It helps accurately convey the patient’s experience and symptoms
This practice enhances the clarity and reliability of the report.
What patient information should be documented regarding medications?
- All prescribed medications
- Herbal remedies
- Diet plans
This may be included in a separate section or as part of the past medical history.
What does GCS stand for in the context of a PCR?
Glasgow Coma Scale
It is used to assess a patient’s level of consciousness.
What is the purpose of electronic PCR (ePCR)?
To reduce writing and ensure consistency across PCRs
However, it may limit the ability to provide detailed narratives.
