Questions and Answers
What is the purpose of documenting the chief complaint?
Which of the following best describes the ongoing assessment?
In the narrative, what is required if a patient with injury refuses treatment?
What must be confirmed after airway placement?
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What should be included in the notes section of patient care reports?
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Which information is NOT part of the primary assessment?
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Why is a notification made to the Medical Battalion Chief when an AED is used?
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What does the secondary/focused assessment involve?
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What is the purpose of the policy regarding patient care reporting?
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Which software has been approved by medical control for electronic patient care reporting?
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What is the maximum time allowed to complete an ePCR after incident notification?
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Which element is NOT explicitly required in the ePCR narrative?
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What format should the ePCR narrative follow?
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Which of the following is a responsibility of the EMT or Paramedic in the narrative?
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Which of the following is true about vital sign documentation in patient encounters?
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What kind of information is required to be included in the ePCR?
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What must the EMT ensure when a patient refuses care?
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What should the ePCR report writer do after selecting the patient disposition of 'refusal'?
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What happens if the signed refusal form cannot be scanned and uploaded into the ePCR?
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Who is responsible for ensuring all ePCRs assigned to personnel are complete and locked?
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Which of the following is NOT a base activator for initiating a Level 1 review?
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What is the primary purpose of the quality improvement program mentioned?
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Who coordinates the efforts of the quality assurance program?
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What must be documented when a patient refuses care during the ePCR process?
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What is the primary focus of a Level 1 review in the Quality Improvement Program?
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Under what circumstances does a review elevate to Level 2?
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Who is responsible for initiating a Level 2 review?
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What is the role of the Medical Battalion Chief in the Level 2 review process?
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At what point does a review escalate to Level 3?
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What is required to be forwarded with a request for a Level 3 review?
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Who ultimately conducts the Level 3 reviews?
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What is the maximum time allowed for completing a Level 1 review after assignment?
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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.