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• Exams• Documentation• Communication
IHERN• Peds
Autism• Geriatrics• Clinical Rotation• Homework assignment
DOCUMENTATION
Pre-hospital Care Report
• Computerized
direct data entry
electronic clip boards
pen based computers
PDA
Complete report while still fresh in your mind
Patient Care Reports• Become permanent part of record• Legal document• Administration
insurance and billing info• Education and research• QI
Documentation
• Confidentiality
Health Insurance Portability and Accountability Act
• Patient Refusal
Falsification• Two types of errors
OmissionCommission
actions that were wrong or improper. Document thoroughly and contact medical direction.
• If it’s not documented, it wasn’t done
• If it’s not done, don’t document it
• Repercussions
suspension or revocation of cert.
false impression of pt. care is passed on
Correcting Errors
Special situations
• Multiple-casualty incidents
use triage tags
Special situation reports• Exposure to infectious disease• Injury to self or another EMT• Hazardous or unsafe scenes of which
other crews should be alerted• Referral to Social Service agencies
remain accurate and objective