DOCUMENTATION-medic

DOCUMENTATION-medic - DOCUMENTATION Volume 2, Chapter 6...

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DOCUMENTATION Volume 2, Chapter 6 EMSTA Jennifer Cochran, RN, BSN, MICN
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Importance of Documentation Provides for the following: A written record of the incident A legal record of the incident Professionalism Medical audit Quality improvement Billing and administration Data collection
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“The content and completeness of the pre-hospital care report directly affects the lawyer’s impression of the incident and influences his decision of whether or not to file a lawsuit.” Richard A Lazar, JD
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Written Record of Incident May be the only source of information for persons subsequently interested in the event Record of the incident from beginning to end Provides a source of identifying pertinent reportable clinical data from each patient reaction
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Introduction Your written prehospital care report (PCR) is the only true factual record of events. Your PCR is your sole permanent, complete written record of events during the ambulance call.
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Uses for PCRs Medical Administrative Response times Billing Research Legal
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Characteristics of a Well-Written PCR Medical Terminology “Belly” vs “Abdomen” “puking all over” vs “moderate amount of emesis” “Obviously Drunk” – how could you reword this??
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Characteristics of a Well-Written PCR Abbreviations and Acronyms What does CP mean? What does CO mean? What does BS mean? Use them cautiously!!
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Characteristics of a Well-Written PCR Times Try to use the same clock Don’t use “15 minutes ago” Use exact times On scene time may not be the time you reach the patient
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Characteristics of a Well-Written PCR Communications Document BHO and BHPO direction and outcomes Document turnover
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This note was uploaded on 03/25/2010 for the course PAR 100 taught by Professor Alan during the Spring '10 term at Miramar College.

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DOCUMENTATION-medic - DOCUMENTATION Volume 2, Chapter 6...

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