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Questions and Answers
What information needs to be populated in the 'Patient Details' tab?
The ePCR must be completed before the medical scenario starts.
False
What is the purpose of the CPIs mentioned?
To audit and highlight areas for improvement in patient care.
The _____ scenario involves a trauma situation.
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Match the scenarios with their respective focus areas:
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What is the purpose of the Patient Report Form (PRF)?
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All patient findings, positive and negative, are equally important in documentation.
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What does ePCR stand for?
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A patient is only ‘well’ if you assess and document your findings _____ .
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Match the following documentation practices with their descriptions:
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Which of the following practices is discouraged in creating ePCRs?
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You should always save time by using pre-written information for ePCRs.
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The white copy of the PRF is given to the _____ on handover.
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Study Notes
ePCR Overview
- Electronic Patient Care Record streamlines documentation of patient care.
- Paper Patient Report Form (PRF) serves as a medical and legal record.
Importance of PRF
- Complete all sections on the PRF, ensuring accuracy.
- White copy is given to Healthcare Professional (HCP) during handover.
- PRF must be submitted with LA1 at the end of each shift.
Medical Model Documentation
- Document history and assessment findings systematically.
- Key categories include:
- HPC (History of Presenting Complaint)
- PMH (Past Medical History)
- PSH (Past Surgical History)
- FHX (Family History)
- SHX (Social History)
- DHx (Drug History)
- Birth History
- IMP (Impression)
- Plan
- Both positive and negative findings are critical for comprehensive evaluation.
Documentation Standards
- Maintain legibility; errors should be corrected with a single neat line.
- Accurate assessment and documentation confirm the patient's well-being.
Abbreviation Guidelines
- Utilize standard, accepted abbreviations for clarity.
- Avoid vague or humorous abbreviations to maintain professionalism.
ePCR App Usage
- All entries in ePCR must be contemporaneous.
- Avoid pre-written or copied information; each record must reflect the actual patient encounter.
- No accidental deletions are possible in the app, reinforcing data integrity.
Personal Demographic Service (PDS)
- Patient details must include name, date of birth (DoB), and postcode.
- Utilize PDS for healthcare planning, DNACPR (Do Not Attempt Cardiopulmonary Resuscitation), and patient information tracking.
Scenario-based Training
- Participants will engage in medical and trauma scenarios to practice ePCR completion.
- Additional questions regarding ePCR can be addressed post-scenario.
Continuous Quality Improvement (CPI) and Auditing
- CPIs support improvement in patient care quality.
- Areas of focus for audit include:
- Cardiac arrest management
- Sepsis protocols
- Non-conveyed incidents
- Mental health assessments
- Sickle cell issues
Questions and Clarifications
- Encouragement to ask questions for clarity regarding ePCR usage and protocols.
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Description
This quiz covers the key aspects of the Electronic Patient Care Record (ePCR) and the significance of the Paper Patient Report Form (PRF) in medical documentation. It highlights the systematic approach to documenting patient history and assessment findings as well as the importance of maintaining accuracy and legibility in patient records.
