Patient Care Documentation Standard Operating Procedure Quiz

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Questions and Answers

What is the purpose of the Clark County EMS System Emergency Medical Care Protocols (EMCP)?

  • To establish guidelines for EMS personnel in a different county.
  • To outline the procedures for fire emergencies in Las Vegas.
  • To regulate the traffic rules during emergency responses.
  • To provide guidance and standardization of prehospital patient care in Clark County. (correct)

What is emphasized as the responsibility of all LVFR personnel regarding documentation?

  • To follow the instructions within the Patient Care Documentation Manual (PCDM). (correct)
  • To disregard documentation requirements.
  • To create their documentation standards.
  • To memorize all LVFR EMS Task Standards.

When should an individual be considered a patient?

  • When there are doubts about their health condition.
  • Only if they have visible injuries.
  • When they request evaluation for potential illness or injury. (correct)
  • When they are informed about possible illness.

What is the purpose of the Las Vegas Fire & Rescue EMS Task Standards?

<p>To provide care recommendations for specific patient groups. (A)</p> Signup and view all the answers

Based on the text, what is one of the responsibilities of LVFR personnel related to documentation?

<p>To be familiar with and follow the documentation requirements within the PCDM. (D)</p> Signup and view all the answers

Why are the criteria mentioned in the text intended to be considered in the widest sense?

<p>To ensure that all individuals are treated as patients if necessary. (D)</p> Signup and view all the answers

What does LVFR stand for in the context provided?

<p>Las Vegas Fire &amp; Rescue (A)</p> Signup and view all the answers

What type of care recommendations do the LVFR EMS Task Standards offer?

<p><strong>Clear and succinct</strong> care recommendations for specific patient groups (D)</p> Signup and view all the answers

Who are the required signatures for all PCRs in which the patient was transported by LVFR?

<p>EMS Technician, Registered Nurse (RN), and Medical Doctor (MD) (B)</p> Signup and view all the answers

What is the additional documentation requirement if unable to obtain the patient, guardian, or authorized representative signature?

<p>Refer to the PCDM: Unable to Sign (D)</p> Signup and view all the answers

When must the associated Monitor file be uploaded and attached to the PCR?

<p>When obtaining a 12-lead electrocardiogram (ECG) (B)</p> Signup and view all the answers

What should be done if the file upload and attachment process for associated Monitor file does not work properly?

<p>Print the code summary report and send it to EMS Quality Improvement Coordinator (D)</p> Signup and view all the answers

What does the Medical Records Confidentiality Act of 1995 aim to ensure?

<p>Confidentiality of all medically related records (C)</p> Signup and view all the answers

What is Protected Health Information (PHI) defined as?

<p>Any information, including demographic information, from an individual (A)</p> Signup and view all the answers

When should a PCR associated with a patient who was not transported be completed?

<p>Within four (4) hours of the unit status changing to In Quarters (D)</p> Signup and view all the answers

What methods are used to document all patient encounters?

<p>Completion of checkboxes, flowcharts, flex fields, and a descriptive narrative (B)</p> Signup and view all the answers

Which information is required to be included in the PCR according to the EMCP?

<p>Incident number, unit number, and patient date of birth (C)</p> Signup and view all the answers

If a patient is transported to a receiving facility, when should the associated PCR for the patient be completed?

<p>Before the unit leaves the receiving facility (C)</p> Signup and view all the answers

What is defined as Essential elements in documenting patient care?

<p><strong>Completion of appropriate checkboxes, flowcharts, flex fields, and a descriptive narrative</strong> (D)</p> Signup and view all the answers

Who is responsible for the content, revision, and review of the information regarding patient care documentation?

<p>The Deputy Chief of Emergency Medical Services (EMS) (C)</p> Signup and view all the answers

What is the purpose of establishing the LVFR policy on patient care documentation?

<p>To document patient assessment and care by LVFR personnel (D)</p> Signup and view all the answers

What role does the Company Officer play in relation to patient care documentation?

<p>Ensuring subordinates follow the policy and complete required records (B)</p> Signup and view all the answers

What is a Patient Care Report (PCR) used for according to the information provided?

<p>Documentation of patient assessment and care by medical providers (A)</p> Signup and view all the answers

When does a person qualify as a 'Patient' according to the Emergency Medical Care Protocols (EMCP)?

<p>All of the above (D)</p> Signup and view all the answers

What is the expiration date mentioned in the Standard Operating Procedure for Patient Care Documentation?

<p>7/28/2024 (D)</p> Signup and view all the answers

Who is responsible for being familiar with patient care documentation requirements according to the information?

<p>All LVFR personnel (D)</p> Signup and view all the answers

What documentation is required for all incidents in which a patient refuses treatment and/or transportation against medical advice?

<p>A complete patient assessment and vital signs (C)</p> Signup and view all the answers

What does the provider impression need to reflect for a patient who refuses care?

<p>Efforts to encourage the patient to accept care (B)</p> Signup and view all the answers

Which Run Disposition requires at least two full sets of vital signs for documentation?

<p>Treated/No Transport (A)</p> Signup and view all the answers

What aspect is crucial for documenting in the case of patient refusals against medical advice?

<p>Description of the patient and reasons for refusal (B)</p> Signup and view all the answers

When documenting patient care transfer, what information should be included?

<p>Time of care transfer and recipient details (D)</p> Signup and view all the answers

What should be explained to a patient who is refusing care according to the text?

<p>Risks associated with refusing care (B)</p> Signup and view all the answers

What is one of the required elements for documenting incidents where a patient refuses treatment and/or transport?

<p>Recommendation of treatment and/or transport to the patient (B)</p> Signup and view all the answers

In the case of patients treated under which Run Disposition, at least two full sets of vital signs are required?

<p>Treated/Transported (B)</p> Signup and view all the answers

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