Chapter 6 Documentation

Question 1

What is the CHARTE method?

Answer 1

A narrative writing method that allows the narrative to be broken down into logical sections similar to the steps of the patient assessment; components include chief complaint, history, assessment, treatment, transport, and exceptions.

Question 2

What is double documentation?

Answer 2

The act of documenting the care and treatment provided at an incident more than once, which increases the risk of errors and inconsistencies.

Question 3

What is emergency medical dispatch (EMD)?

Answer 3

A system that assists dispatchers in selecting appropriate units to respond to a particular call for assistance and provides callers with vital instructions until the arrival of EMS crews.

Question 4

What is libel?

Answer 4

A false statement in written form that could be harmful to a person’s current or future reputation.

Question 5

What is medical necessity?

Answer 5

A standard used by Medicare to determine whether a patient’s condition requires ambulance transport in a particular situation.

Question 6

What is the minimum data set?

Answer 6

The mandatory clinical assessment standard information that must be documented on every emergency call, as determined by Medicare and Medicaid, and per the National Highway Traffic Safety Administration for the purpose of informing the national data system.

Question 7

What is a near miss?

Answer 7

An unplanned event that did not cause an injury, illness, or damage, but had the potential to do so.

Question 8

What is objective information?

Answer 8

Information that is observable and measurable, such as a patient’s blood pressure.

Question 9

What is a patient care report (PCR)?

Answer 9

A legal document used to record all patient care activities during an incident; a handwritten or electronic report that describes the nature of the patient’s injuries or illness at the scene and the treatment provided; also known as the prehospital care report.

Question 10

What are pertinent negatives?

Answer 10

A record of negative findings that warrant no medical care or intervention, but which show evidence of the thoroughness of the patient exam and history.

Question 11

What is slander?

Answer 11

A false verbal statement that injures a person’s good name.

Question 12

What is the SOAP method?

Answer 12

A narrative writing method in which information is organized into four categories: Subjective information, Objective information, Assessment, and Plan (for treatment).

Question 13

What is subjective information?

Answer 13

Information that is obtained from the patient but cannot be seen, such as the symptoms a patient describes.