Volume 2 Chapter 6

  1. Prehospital Care Report (PCR)
    The written record of and EMS response
  2. Uses for PCRs
    • Medical
    • Administrative
    • Research
    • Legal
  3. Response Time
    Time elapsed from when a unit is alerted to when it arrives on scene
  4. Bubble Sheet
    Scannable run sheet on which you fill in boxes or bubbles to record assessment and care information
  5. Characteristics of a Well-Written PCR
    • Appropriate medical terminology
    • Correct abbreviations and acronyms
    • Accurate, consistent times
    • Thoroughly documented communications
    • Pertinent negatives
    • Relevant oral statements of witnesses, bystanders and patient
    • Complete identification of all additional resources and personnel
  6. Elements of Good Documentation
    • Complete
    • Accurate
    • Legible
    • Timely
    • Without alterations
    • Professional
  7. Addendum
    Addition or supplement to the original report
  8. Jargon
    Language used by a particular group or profession
  9. Libel
    Writing false and malicious words intended to damage a person's character
  10. Slander
    Speaking false and malicious words intended to damage a person's character
  11. Approaches to the Physical Exam
    • Head to toe
    • Body systems
  12. Field Diagnosis
    What you believe to be your patient's problem based on your history and physical exam
  13. Narrative Formats
    • SOAP
    • CHART
    • Patient management
    • Call incident
  14. SOAP
    • Subjective
    • Objective
    • Assessment
    • Plan
  15. CHART
    • Chief complaint
    • History
    • Assessment
    • Rx(treatment)
    • Transport
  16. Against Medical Advice (AMA)
    Your patient refuses care even though you feel he needs it
  17. Triage Tags
    Tags containing vital information affixed to your patient during an MCI
Card Set
Volume 2 Chapter 6
Volume 2 Chapter 6