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working toward the goal of optimal excellenc3e int h services rendered to every patient; includes review of the PCR
cotinouous quality improvement
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discoloration of body tissues in the lower or dependent areas of the body, caused by the collection of coagulated blood
dependent lividity
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the end fo life wishes recorded in writing by the patient before death, to stop any resuscitation attempts in case of cardiac arrest
DNR order
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national organization that defines what to document in prehospital care reports, setting standards with EMS experts, and ultimatly to srve as data collection center to promote research
National emergency medical services informatio system (NEMSIS)
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physical signs that can be visualized by the EMT
objective findings
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identification information provided by the patient or by family or friens; includes patient's name, age, gender, dob, and address
Patient Data
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the standardized patient record used in the EMS system
Patient care report
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state of body stiffness caused by the depletion of proteins in muscles after death
rigor mortis
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the part of the documentation that records the location, type of call, and times related to the response
run data
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symptoms reported by the patient but not seen by the EMT
subjective findings
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special tag with more limited but critical information on a patient's status, attached to patients in a MCU
triage tag
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symbole for male
circle with arrow on top right
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symbol for a woman
circle with cross at the bottom
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abb for before
a with a line over it
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abb for blood pressure
BP
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abb for with
c with a line over it
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abb for coplaining of
c/o
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abb for cardiopulmonary resuscitation
CPR
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abb for date of birth
DOB
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abb for Left lower quadrant
LLQ
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abb for Left upper quadrant
LUQ
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abb for Oxygen
O with a small a small to on the bottom right
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-
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abb for Physical examination
Px
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abb for Right lower quadrant
RLQ
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abb for Right upper quadrant
RUQ
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abb for Shortness of breath
SOB
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the effectiveness of a PCR depends on
- 1.) accuracy and honesty
- 2.) clarity
- 3.) chronology and trends
- 4.) completeness
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patient assessment data includes:
critical signs and symptoms, cheif complaint, vital signs, mental status, assessment of the skin
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patient treatment data
treatment, transportation method, time of transport, and notification to the hospital
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how do you correct an error on the PCR
draw a horizonal line through it and initial date and time.
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