Patient Assessment
This is the first step in a patient assessment.
Scene Safety
This acronym stands for the record of events surrounding a patient's medical history and care.
Patient Care Report (PCR)
This term refers to permission granted by the patient to allow medical treatment.
Consent
True or False: All incidents, even minor ones, should be documented.
True
What does CPR stand for?
Cardiopulmonary Resuscitation
These are the components of the SAMPLE history.
Signs/Symptom, allergies, medications, past history, last oral intake, and events
What are the four components of SOAP documentation?
Subjective, objective, assessment, plan
What is the Good Samaritan Law?
Legal protection for those who give assistance during a medical emergency
What is the purpose of incident reports?
To identify trends, improve safety, and prevent future incidents
This abbreviation stands for "as needed" medication
PRN
What does OPQRST stand for in patient assessment?
Onset, provocation, quality, radiation, severity, and time
This section of the PCR includes details about the patient's allergies, medications, past medical history, etc.
Medical History
True or False: EMTs have the authority to diagnose medical conditions.
False. They make differential diagnosis
This acronym stands for the process of evaluating and improving the quality of patient care.
Quality Improvement (QI)
What does ROSC stand for in the context of resuscitation efforts?
Return of Spontaneous Circulation
This vital sign is often abbreviated as "BP."
Blood pressure
This term refers to the accuracy, clarity, and thoroughness of written documentation.
Legibility
This type of consent is implied in situations where the patient is unable to provide consent due to unconsciousness or severe injury.
Implied consent
Describe the "Crew Resource Management" concept in incident reporting.
A process that emphasizes communication, teamwork, and decision-making among crew members
What does DCAP-BTLS stand for in patient assessment?
Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, Swelling
What does AVPU stand for when assessing a patient's level of consciousness?
Alert, verbal, painful, and unresponsive
True or False: It is acceptable to use patient nicknames or abbreviations in a PCR.
False
What is the significance of HIPAA in patient documentation?
Ensuring patient confidentiality and privacy
What information should be included in an incident report following a patient fall?
Mechanism of injury, patient assessment findings, interventions performed
What does AED stand for?
Automatic External Defibrillator