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9 Cards in this Set
- Front
- Back
The sole permanent, complete written record of events during an ambualnce call, considered the most comprehensive and reliable record of the event, and it reflects your professionalism is called ?
|
PCR
(Patient Care Report) (p 736) |
|
Name the 4 uses of your PCR
|
1-Medical
2-Administrative 3-Research 4-Legal (P736) |
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What becomes a permanent part of your PT's medical record?
|
PCR
(p 737) |
|
Never write _____ ______ in your PCR's
ex. "the pt is drunk, obnoxious, and looks like a crack addict" |
Subjective Opinions
(p 738) |
|
An essiential component of good documentation is the appropriate use of _____ _______.
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Medical terminology/terms
(p 738) |
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*Appropriat medical terminology
*correct abbreviations/acronyms *accurate, consistent times *thoroughly documented communications * pertinent negatives * relevant oral statements of witnesses * complete ID's of all ADDT'L resources and personnel All are ? |
Characteristics of a Well-Written PCR
(p738) |
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Name a major problem with using Medical abbreviations/acronyms?
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Medical abbreviations/acronyms sometimes have multiple meanings
(P 738) |
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The times recorded on the PCR are considered?
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The OFFICIAL times of the incident (743)
|
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A common problem with documenting times is the?
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Inconsistencies of the dispatch center clock, ambulance clock, and your watch
(P 743) |