Patient Care Reporting & Quality Review Guideline
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Questions and Answers

What is the purpose of documenting the chief complaint?

  • To provide a summary of the patient's medical history.
  • To assess the effectiveness of treatments provided.
  • To document the patient's expressed health issues. (correct)
  • To fulfill legal requirements for patient care.

    • Which of the following best describes the ongoing assessment?

  • The response of the patient to treatments and medications. (correct)
  • A review of the transferring EMS agency.
  • The patient's past medical history.
  • The initial encounter with the patient.

    • In the narrative, what is required if a patient with injury refuses treatment?

  • You should provide a verbal explanation instead of documentation.
  • You must document the refusal in detail as any other patient. (correct)
  • Only the patient’s information needs to be recorded.
  • You do not have to document anything in this case.

    • What must be confirmed after airway placement?

    <p>Lung sounds and chest rise.</p> Signup and view all the answers

    What should be included in the notes section of patient care reports?

    <p>Details on the transporting EMS agency.</p> Signup and view all the answers

    Which information is NOT part of the primary assessment?

    <p>Blood glucose level.</p> Signup and view all the answers

    Why is a notification made to the Medical Battalion Chief when an AED is used?

    <p>To ensure downloading of AED data for analysis.</p> Signup and view all the answers

    What does the secondary/focused assessment involve?

    <p>Assessment of lung sounds and pertinent negatives.</p> Signup and view all the answers

    What is the purpose of the policy regarding patient care reporting?

    <p>To establish minimum requirements for patient care reporting and quality review</p> Signup and view all the answers

    Which software has been approved by medical control for electronic patient care reporting?

    <p>ImageTrend 'Field'</p> Signup and view all the answers

    What is the maximum time allowed to complete an ePCR after incident notification?

    <p>24 hours</p> Signup and view all the answers

    Which element is NOT explicitly required in the ePCR narrative?

    <p>Family history</p> Signup and view all the answers

    What format should the ePCR narrative follow?

    <p>Chronological format</p> Signup and view all the answers

    Which of the following is a responsibility of the EMT or Paramedic in the narrative?

    <p>Explaining treatment information</p> Signup and view all the answers

    Which of the following is true about vital sign documentation in patient encounters?

    <p>Vital signs must be documented for each encounter</p> Signup and view all the answers

    What kind of information is required to be included in the ePCR?

    <p>Accurate and relevant medical incident information</p> Signup and view all the answers

    What must the EMT ensure when a patient refuses care?

    <p>The STJFD patient refusal form is completed and signed by the patient.</p> Signup and view all the answers

    What should the ePCR report writer do after selecting the patient disposition of 'refusal'?

    <p>Document the patient's orientation and education of refusal within the designated tab.</p> Signup and view all the answers

    What happens if the signed refusal form cannot be scanned and uploaded into the ePCR?

    <p>It should be placed in a sealed envelope and delivered to headquarters within 48 hours.</p> Signup and view all the answers

    Who is responsible for ensuring all ePCRs assigned to personnel are complete and locked?

    <p>The Medical Battalion Chief.</p> Signup and view all the answers

    Which of the following is NOT a base activator for initiating a Level 1 review?

    <p>Medication Administration (oxygen administration included).</p> Signup and view all the answers

    What is the primary purpose of the quality improvement program mentioned?

    <p>To ensure emergency medical care is rendered in a professional and systematic format.</p> Signup and view all the answers

    Who coordinates the efforts of the quality assurance program?

    <p>The Medical Battalion Chief, command staff, and Medical Director.</p> Signup and view all the answers

    What must be documented when a patient refuses care during the ePCR process?

    <p>The patient's orientation and education regarding the refusal.</p> Signup and view all the answers

    What is the primary focus of a Level 1 review in the Quality Improvement Program?

    <p>Compliance with STJFD Standard Operating Guideline 200.07</p> Signup and view all the answers

    Under what circumstances does a review elevate to Level 2?

    <p>When there are identified infractions or deviations from protocol</p> Signup and view all the answers

    Who is responsible for initiating a Level 2 review?

    <p>The EMT or Paramedic conducting Level 1 review</p> Signup and view all the answers

    What is the role of the Medical Battalion Chief in the Level 2 review process?

    <p>Conducting the review and advising the member of the outcome</p> Signup and view all the answers

    At what point does a review escalate to Level 3?

    <p>When further actions are deemed necessary by the Level 2 review findings</p> Signup and view all the answers

    What is required to be forwarded with a request for a Level 3 review?

    <p>All supporting documentation</p> Signup and view all the answers

    Who ultimately conducts the Level 3 reviews?

    <p>Command Staff personnel under consultation with the Medical Director</p> Signup and view all the answers

    What is the maximum time allowed for completing a Level 1 review after assignment?

    <p>14 days</p> Signup and view all the answers

    Study Notes

    Patient Care Reporting & Quality Review

    • The St. Johns Fire District (STJFD) uses electronic patient care reporting (ePCR) software, specifically ImageTrend "Field", to document patient encounters and treatment.

    Patient Care Reporting - General

    • All required fields in the ePCR software must be accurately completed within 24 hours of incident notification.
    • Vital signs must be documented for each patient encounter.
    • The narrative should include observations, interventions, assessment of the patient, and other pertinent information.

    ePCR Narrative

    • The narrative format should be in chronological order, including:
      • Dispatched To: brief description of the initial call for service
      • Upon Arrival: description of the incident scene
    • The narrative should also include:
      • Chief Complaint: patient's expressed chief complaint and secondary complaints
      • Primary Assessment: patient's level of consciousness, airway, breathing, circulation, history of present illnesses, and past medical history
      • Secondary / Focused Assessment: detailed physical exam or focused assessment
      • Treatments: all treatments provided to the patient
      • Ongoing Assessment: patient's response to treatments
      • Notes: description of patient turnover to the transporting EMS agency

    Additional Required Information in the Narrative

    • Airway placement must be confirmed by checking chest rise and lung sounds.
    • Consideration for capnography should be documented.
    • If a patient with injury refuses treatment, the EMT or Paramedic should document findings and complete a medical treatment refusal form.

    Notifications

    • A notification must be made to the STJFD Medical Battalion Chief anytime an automatic external defibrillator (AED) is used.

    Patient Refusals

    • When a patient chooses to refuse care or transport, the EMT must complete and have the patient sign a patient refusal form.
    • The refusal form must be uploaded into the ePCR or delivered to headquarters within 48 hours of the incident.

    Medical Quality Assurance and Improvement

    • The purpose of the quality improvement program is to ensure that emergency medical care is rendered in a professional and systematic format.
    • The Medical Battalion Chief, command staff, and Medical Director are responsible for reviewing emergency medical incidents.

    Formal Quality Improvement

    • The STJFD utilizes a three-level review process for its Quality Improvement Program.
    • Level 1: review of reports that warrant a review based on identified priorities.
    • Level 2: review of reports that identify infractions or deviations from protocol.
    • Level 3: review of reports that require further action, conducted by Command Staff under the consultation of the Medical Director.

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    Description

    This quiz covers the Standard Operating Guideline for patient care reporting and quality review by the St. Johns Fire District. It outlines the minimum requirements and standardized process for patient care reporting and quality assurance review.

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