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What is a PCR and what are they used for?
A written record of an EMS response that can be used for medical, administrative, research or legal purposes.
What is the definition of response time?
The time elapsed from when a unit is alerted until it arrives on scene.
What is research in regards to a PCR?
The PCR provides the basis for continuously improving patient care in the EMS system.
What is one important characteristic of a well written run report?
Complete identification of all additional resources and personnel.
What do the following abbreviations stand for?
- Coronary artery bipass graft
- Paroxysmal nocturnal dyspnea
- After eating
- Before eating
- Post operative/Taken orally
What is the proper way to make a correction to a PCR?
Draw a single line through the error, write the correct information besides it and initial the change.
What is an addendum?
An addition or supplement to the original report.
What is the "CHART" method of report writing?
- Chief complaint
Why is competency an issue regarding documentation?
Patients retain the right to refuse treatment if they're competent to do so. This requires excellent documentation regarding the patients status.
What are some good ways to protect yourself and your service when a patient refuses care?
A thorough patient assessment
Documenting patient competency
Explaination to the patient possible causes of refusing care, including possibility of death when appropriate.
Your willingness to return if they change their mind.
Patients understanding of statements and suggestions and apparent competence to refuse care based on that understanding.
When involved in a MCI what may be impractical?
Obtainig complete patient information or completing documentation before moving on to the next patient. Document as much as possible, as quick as possible then move on to the next patient, keeping the patients best interest in mind.
Inaccurate or incomplete reports can...
encourage or lead to frivolous lawsuits.