TAILIEUCHUNG - mosby paramedic (4)

9/10/20121Chapter of .Documentation3Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Objectives.• Identify the purpose of the patient care .report• Describe the uses of the patient care report• Outline the components of an accurate, .thorough patient care for Written .Documentation.• Provides tangible, legal incident record.• Used by physicians, nurses in patient care.– Read to understand initial condition, type of care given .in field• EMS agency, medical direction may.–.–.–.–Monitor care in individual review other educational for Written .Documentation.• Written documentation provides for.– Tangible record of incident.– Legal record of incident.– Professionalism.– Medical audit.– Quality improvement.– Billing, administration.– Data © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning for .Personal Care Report (PCR).• Demonstrate continuity of patient care provided.• Have legal record of care provided.• Assist financial reimbursement, cost recovery for .care services, equipment, supplies.• Assist in quality improvement studies, EMS research7Reasons for .Personal Care Report (PCR).• Quality improvement.– Examples from PCR that may result in policy .changes, improve care.– Minimizing time spent on scene for critical .trauma patients.– Adding new medications to better manage some .medical emergencies.– Changing placement of emergency vehicles during .peak response times, certain demographic for .Personal Care Report (PCR).• Documents unique scene situations that may .have affected care.– Traffic caused long response time.– Entrapped patient required prolonged extrication• Aids in tracking care skills of paramedic.– IV lines, intubations, defibrillations.– May be required by EMS agency’s training division.– ALS skills documentation may be required by .some states for relicensure, © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Considerations for PCR.• Carefully detailed, legible.• Legal document, part of patient’s medical .record.• Avoid slang terms, medical abbreviations that .are not universally accepted101112Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Considerations for PCR.• Required data.–.–.–.–.–.–.–.–.–Dates, response en for extended on‐scene care of of patient for hospital should you note the previous .care given by bystanders in .your report?14General Considerations for PCR.• Provides legal, accurate recording for .incident times.–.–.–.–.–Call arrival at patient’s of vital sign .assessments– Time(s) of medication .administration, certain .procedures, defined by local .protocol .– Scene departure time.– Medical facility arrival time .when transporting patient.– Time back in © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company5.

• Sáng kiến kinh nghiệm
• Mosby's paramedic
• Mosby's paramedic textbook
• Medical terminology
• EMS systems
• Acute interventions
• Home care
• EMS system development
• Current health care reform
• Prehospital patient care repor
• Patient care report
• Emergency medical services
• Narrative section
• Hazardous materials awareness
• Scope of hazardous materials
• Paramedic’s practice
• Claim of negligence
• Well‐being of the paramedic
• Physical fitness
• Components of wellness