The narrative pertinent negatives refers to

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The Narrative 0 Pertinent Negatives refers to assessment findings that do not require intervention or care, but prove the thoroughness of assessment by caregiver. 0 “Quotation Marks” should be utilized for anything directly stated by patient, family, bystanders, witnesses, etc. 0 Only document objective observations September 2014 JI 6
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Minimum Data Collection Patient information 0 Patient demographics 0 Chief complaint 0 Initial assessment 0 Vital signs Administrative information 0 Time incident reported 0 Time unit notified 0 Time of arrival at patient 0 Time unit left scene 0 Time of arrival at destination 0 Time of transfer of care September 2014 JI 7
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Refusal 0 Refusal of Medical Attention / Transport ( RMA ) is one of the basic rights of a patient 0 Only Alert (A&O x4) adults with decision making capabilities can RMA (Included: emancipated minors) 0 Document thoroughly all occurrences and include: 0 Advised need of transport 0 Advised repercussions of refusal 0 Good clinical judgment and patient competency 0
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  • Spring '17
  • Health care provider

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