Here is a short EMT review about documentation and patient care reports. The following questions help remind us why these reports are important in our career. It is my hope that these questions will help you on your EMT refresher and testing.
Explain the various uses of the documentation that the EMT generates after a patients contact?
Documentation can be used for continuous patient care, administration uses, as legal documents, educational documents, research, evaluation and improvement to the EMS system.
Describe two common formats for the Patient Care Report.
The two most common formats for a PCR is a written form or a computerized report. The computerized format is usually an electronic tablet or handheld device.
Explain the origin and purpose of the minimum data set.
The U.S. Department of Transportation has made an effort to standardize the information collected on a PCR. The purpose is to standardize reporting throughout the United States.
Explain what the phrase "accurate and synchronous clocks" meaning and its importance.
EMS systems should use clocks or time keepers that are accurately set and agreed upon.
Define Pertinent Negatives.
Pertinent negatives are signs or symptoms that might be expected base on the chief complaint but are denied by patient.
List the steps you should take if a patient refuses treatment.
A. Make sure patient is ration and not suicidal
B. Perform as much assessment as possible
C. Inform patient of risks for not obtaining medical care
D. Make last effort to have patient seek care
E. Have patient sign refusal of treatment form that is part of the PCR.
Explain the meaning and importance of the following document rules.
"If it wasn't written down, it wasn't done"
"If it wasn't done, don't write it down"
These two statements pertain to a patients care record. It's important to be exact on these reports. It may be easy to write something down to save face but this can be potentially harmful to the patient and your career.
Describe how errors on PCR should be corrected
An error on a PCR should be corrected by making a line through the mistake and then putting your initials next to it.
Explain how multiple casualty incidents can effect EMT documentation.
All the information may not be collected right at the scene of the incident. A multiple causality incident will cause the need for triage tags. Where name, age, and chief complaint is recorded.
Describe circumstances in which an EMT might be expected to file special reports with other agencies.
A. Child or Elderly neglect
B. Possible contact of diseases
C. Injury to EMS Team
Well I hope that you find these EMT training notes useful. I'll be adding additional notes as EMT classes go on. Please feel free to leave comments. I honestly believe that we can learn from each other.
Explain the various uses of the documentation that the EMT generates after a patients contact?
Documentation can be used for continuous patient care, administration uses, as legal documents, educational documents, research, evaluation and improvement to the EMS system.
Describe two common formats for the Patient Care Report.
The two most common formats for a PCR is a written form or a computerized report. The computerized format is usually an electronic tablet or handheld device.
Explain the origin and purpose of the minimum data set.
The U.S. Department of Transportation has made an effort to standardize the information collected on a PCR. The purpose is to standardize reporting throughout the United States.
Explain what the phrase "accurate and synchronous clocks" meaning and its importance.
EMS systems should use clocks or time keepers that are accurately set and agreed upon.
Define Pertinent Negatives.
Pertinent negatives are signs or symptoms that might be expected base on the chief complaint but are denied by patient.
List the steps you should take if a patient refuses treatment.
A. Make sure patient is ration and not suicidal
B. Perform as much assessment as possible
C. Inform patient of risks for not obtaining medical care
D. Make last effort to have patient seek care
E. Have patient sign refusal of treatment form that is part of the PCR.
Explain the meaning and importance of the following document rules.
"If it wasn't written down, it wasn't done"
"If it wasn't done, don't write it down"
These two statements pertain to a patients care record. It's important to be exact on these reports. It may be easy to write something down to save face but this can be potentially harmful to the patient and your career.
Describe how errors on PCR should be corrected
An error on a PCR should be corrected by making a line through the mistake and then putting your initials next to it.
Explain how multiple casualty incidents can effect EMT documentation.
All the information may not be collected right at the scene of the incident. A multiple causality incident will cause the need for triage tags. Where name, age, and chief complaint is recorded.
Describe circumstances in which an EMT might be expected to file special reports with other agencies.
A. Child or Elderly neglect
B. Possible contact of diseases
C. Injury to EMS Team
Well I hope that you find these EMT training notes useful. I'll be adding additional notes as EMT classes go on. Please feel free to leave comments. I honestly believe that we can learn from each other.
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