TB 98 - Emergency Medical Services Report Writing Flashcards

1
Q

A complete, accurate, and legible EMS Report helps other health care providers plan, coordinate, and document the quality and continuity of each patient’s care.

A well-documented EMS Report reflects:

A

•All patient assessment findings and observations

•The care provided to the patient

•The patient’s response to medication and other treatment interventions

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2
Q

In addition to being used as an EMS Report, the EPCR furnishes the Department with data used for:

A

-patient billing
-EMS quality improvement
-identification of training needs
-aiding in the projection of the future allocation of resources

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3
Q

All members must remember to “_____ and ______” before beginning to complete the EPCR.

A

“assess and intervene”

(Care for the patient always takes priority over documentation of incident information.)

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4
Q

When documenting on the EPCR: enter factual, OBJECTIVE observations and findings only.

Avoid recording personal OPINIONS, SPECULATIVE remarks, or PRESUMPTIONS.

Since ALL MEMBERS whose signatures appear on the document are assumed to concur with its contents, it is imperative that the form be ________

A

read prior to signing.

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5
Q

As our written reports often reflect directly UPON US, clear, concise, and ______ reports are a necessity.

A

complete

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6
Q

Although most members use the teletype printout to record their incident notes, many have found preprinted scratch pads to be helpful.

The two LEAST professional, and therefore least advisable method, is writing on?

A

Writing on hand or gurney sheets

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7
Q

Complete the EPCR as soon as possible AFTER the resolution of each incident.

If transporting, when is it best to complete the EPCR?

A

At the receiving facility.

(This affords optimal patient care, both on scene and during transport)

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8
Q

To maximize the clarity of documentation, a CHRONOLOGICALLY ORDERED written commentary is advisable.

This orderly arrangement should encompass:

A

•Any delayed response information

•Initial observations of the scene

•Baseline patient assessment findings

•Treatment interventions rendered

•The patient’s response to such care

•Information regarding the patient’s final disposition/incident resolution

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9
Q

It is inherently more reliable and credible to use the patient’s and/or bystander’s OWN WORDS in documentation.

Utmost accuracy can be attained by recording the patient’s responses to _____ and ______ assessment questions.

A

PQRST and SAMPLE

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10
Q

How should a patient’s/bystander’s own words be documented during an assessment?

A

Their direct quotes should be identified with Quotation Marks.

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11
Q

Do not erase, write over, scribble out, or white out entries, as this may imply an intent to falsify documents.

Errors or mistakes must be legible even after they have been corrected. Therefore, the “_______” method of correction should be utilized.

A

line-through method.

(Use a single line to indicate an unwanted entry. Place your initials ABOVE the lined-through entry)

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12
Q

Should you need to enter information that is late, write it in, and note “LATE ENTRY.”

What else should be included to signify the late entry?

A

Include the date and time the late entry was made and initial it.

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13
Q

The greatest potential for criticism arising from EMS incidents occurs in what situations?

A

in those situations in which no “hands on” patient contact was made (i.e., no patient assessment was performed and/or no vital signs were taken).

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14
Q

The basic premise of most law suits involving charges of negligence, improper treatment, or omissions of care stems from the allegation that members FAILED to perform to an appropriate STANDARD OF CARE.

The legal standard for evaluating the quality of care is generally based on?

A

A member’s ACTIONS (or inactions) in comparison to the generally accepted standard of care.

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15
Q

As our EMS system evolves toward standing orders, members will be better equipped to render appropriate patient care if they frequently review the “Three Ps”:

A

policies, procedures, and protocols.

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16
Q
  1. Reference No. _____ and Reference No. _____ of the Prehospital Care Policy Manual (LAFD Book 33) requires base hospital contact on “patients meeting base contact criteria (Sections I and/or II) who refuse indicated treatment and/or transport.”
  2. Providers are further compelled to “exercise clinical judgment as to whether base contact should be made,” on incidents not otherwise specifically delineated in Reference No. _____.
A

(1) Reference No. 808 and Reference No. 834

(2) Reference No. 808

17
Q

It is extremely essential to remember that only those patients who are fully ALERT and ORIENTED may sign out AMA.

Therefore, be especially cautious with patients under the influence of alcohol, drugs/medications, altered psychological states, or who may be _______.

A

hypotensive

18
Q

Before a patient refusal can be legally accepted, patients must be “competent” and therefore able to understand completely:

A

•The nature of their medical problem

•The necessity for treatment and/or transportation

•The potential risks and consequences of their refusal

•The urgency of calling 9-1-1, if their condition worsens or if they change their mind regarding treatment and/or transportation

19
Q

Assuring patient safety is one of our most important responsibilities. To prevent a patient from seriously injuring himself/herself and/or others, restraints may be necessary.

Be sure to carefully document:

A

•Why the patient needed to be restrained

•When you first applied the restraints

•How you supervised their use (i.e., distal extremity circulation and neurological assessments [sensory and motor])

•Why you stopped using the restraints

•When you stopped using the restraints

20
Q

Other potentially “high-risk” incidents are those documented as “SLEEPING ONLY. “

Recording ______ findings will decrease the likelihood of leaving a person with a possible medical emergency on scene.

A

mental status findings

21
Q

Patients ETOH:

If the patient is unable to care for himself/herself and is in need of no emergency medical care, record the unit number of the ________ that assumed responsibility for him/her.

(It should be noted that acute alcohol poisoning is life-threatening and therefore members must use extreme caution before releasing anyone under the influence of alcohol.)

A

law enforcement officer

22
Q

EMS Report Writing Bullet Points:

A

-Know the reporting form

-make clear, concise, and complete entries

-use approved terminology and abbreviations

-keep accurate incident notes

-Sequence the report CHRONOLOGICALLY

-document assessment findings from MOST to LEAST SEVERE

-include pertinent NEGATIVE FINDINGS

-use patient’s/bystander’s own words

-identify corrections clearly

-be alert to potentially high-risk medical/legal situations

23
Q

State the Approved Medical Abbreviations for the following (the unconventional ones):

  1. As Needed
  2. Treatment
  3. Before
  4. Fracture
  5. History
  6. Symptom
  7. With
  8. Without
  9. By Mouth
  10. Diagnosis
  11. Each/Every
  12. Liters Per Minute
  13. Occasional
A
  1. As Needed = PRN
  2. Treatment = TX
  3. Before = a
  4. Fracture = FX
  5. History = HX
  6. Symptom = SX
    _
  7. With = c
    _
  8. Without = s
  9. By Mouth = PO
  10. Diagnosis = DX
  11. Each/Every = q
  12. Liters Per Minute = L/MIN
  13. Occasional = OCC