EMS Report Writing

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Questions and Answers

What does JVD indicate in a trauma assessment?

Fluid overload or cardiac issues (correct)

Airway obstruction

Deformities in the neck

Infection in the throat

Which of the following signs indicate potential respiratory distress?

Weak peripheral pulses

Bradycardia

Shallow breathing (correct)

Audible wheezing (correct)

During a head and neck assessment, what is considered a significant finding?

Absence of hives

Facial droop (correct)

Earwax buildup

Equal pupil sizes

What characterizes arterial hemorrhage?

Bright red blood that spurts Signup and view all the answers

What does a finding of distention in the abdomen suggest?

An underlying injury or trauma Signup and view all the answers

What does A&O x4 signify in a medical context?

Alert and oriented to person, place, time, and event Signup and view all the answers

Which abbreviation represents the condition known as atrial fibrillation?

A-FIB Signup and view all the answers

What does the abbreviation DNR stand for in medical terminology?

Do not resuscitate Signup and view all the answers

Which abbreviation is used to describe a procedure for removing a baby through surgical means?

C-SECTION Signup and view all the answers

What does the abbreviation BGL refer to in a medical setting?

Blood glucose level Signup and view all the answers

What does 'MI' stand for in medical terminology?

Myocardial Infarction Signup and view all the answers

Which term describes a medical condition that involves 'sudden infant death syndrome'?

SIDS Signup and view all the answers

In medical context, what does 'PE' refer to?

Pulmonary Embolus Signup and view all the answers

What does 'NC' stand for in oxygen delivery systems?

Nasal Cannula Signup and view all the answers

What is the meaning of 'PRN' in a medical prescription?

Take as needed Signup and view all the answers

What must be documented following the administration of a medication?

Vital signs Signup and view all the answers

What is required for non-patient refusals according to the guidelines?

A refusal signature sheet in the RMS Signup and view all the answers

In a multiple patient incident, who is responsible for setting the status of the associated fire incident to complete?

The incident commander or company officer Signup and view all the answers

How many sets of vital signs must be documented if a patient refuses treatment but is not within normal limits?

Two sets Signup and view all the answers

What must be documented if a patient refuses to have their vital signs taken?

The risks and benefits discussed Signup and view all the answers

What needs to happen after completing an EMS report?

The report must be marked as reviewed and locked Signup and view all the answers

What is required from each author when multiple patient records are created?

Each author should complete their own records Signup and view all the answers

What should be included in the electronic patient care report (EPCR)?

All information obtained from the patient Signup and view all the answers

What should the documentation provided by BCFR personnel include when riding in with AAS?

Changes in the patient's condition during transport. Signup and view all the answers

What is the correct procedure if the Records Management System (RMS) becomes unavailable?

Notify the company officer to escalate the issue. Signup and view all the answers

What is required from a patient or their representative regarding billing authorization?

Written authorization to acknowledge HIPAA. Signup and view all the answers

What must be included in the Chief Complaint section of the PCR?

The patient's age, sex, and weight. Signup and view all the answers

Which of the following is NOT a required aspect of the medical assessment?

Pupil dilation. Signup and view all the answers

What does a signature from the EMT/Paramedic verify in the documentation?

The accuracy of the report and care provided. Signup and view all the answers

In the event of an EMS report request, who should the request be directed to?

The EMS division. Signup and view all the answers

What should be included in the pertinent negatives and positives section during patient assessment?

Relevant information from witnesses on the scene. Signup and view all the answers

Study Notes

Patient Care Reports

Documentation required: detailed description of patient's condition and treatment provided.
Medication administration: requires documentation of medication name, dosage, route, time, and reason for administration.
Medication non-administration: reasons for non-administration should be documented.
Vital signs monitoring: document vital signs before and after medication administration.
Report completion: Company officer and/or paramedics are required to review and lock the completed report.
Multiple patient incidents: each author should complete their respective patient record. Incident commander or company officer authorizes the end of the report.
Non-patient refusals: require a completed refusal signature sheet in the RMS with electronic signature or a refusal document submitted to the EMS division.
Patient refusals: require documented vitals, reason for refusal, and discussion of risks and benefits. Protocol must be followed and refusal criteria should be documented.
AAS transport: Provide documentation of any treatment or actions performed while riding into the hospital, along with any changes in the patient's condition.

Report Management System (RMS)

System failure contingency: Notify Company Officer, Battalion Commander, and Division Chief of EMS.
Reports must be entered into the RMS once it becomes available.

Public Requests

Requests to view or obtain copies of EMS reports must be made directly to the EMS division.

Billing Requirements

Patient or patient representative signature is required to authorize billing and acknowledge HIPAA guidelines.
If the patient or representative is unable to sign, the EMT must sign authorizing HIPAA and billing.
EMT signature required to verify medically necessary transport.
Signature required from the person who patient was turned over to at the hospital.
EMS provider signature required to verify care provided and report accuracy.

PCR Reference

Dispatch information: includes dispatched units, response code, and reported complaint.
Chief Complaint: Age, sex, weight, and C/C (Chief Complaint).
HPI (History of Present Illness): description of the complaint, including duration, previous occurrences, and OPQRST when applicable.
Assessment: includes medical and trauma assessments with detailed findings for each body system.

Medical Assessment

How Patient Was Found: Describe patient's condition upon arrival.
LOC (Level of Consciousness): use AVPU scale.
Airway: describe airway characteristics like open, self-maintained, stridor, secretions, trauma, swelling.
Breathing: describe breathing characteristics like rhythm, depth, and sounds.
Circulation: describe circulation characteristics like color, temperature, and presence of hives or hemorrhage.
Pulses: describe pulse characteristics like rhythm, strength, and rate.
HEENT (Head, Eyes, Ears, Nose, Throat): describe any specific finding for each area.
Neck/Back: describe any deformities or bruising.
Chest: describe any abnormal findings.
ABD: describe any abnormal findings like distention, rigidity, rebound tenderness, bruising, and quadrant affected.
Pelvis: describe any abnormal findings.
Limbs: describe any abnormal findings like CMS (circulation, motor, sensation), weakness, numbness, tingling, edema, discoloration, or ambulation.

Trauma Assessment

How Patient Was Found: describe patient's condition upon arrival.
LOC: use AVPU scale.
Airway: describe airway characteristics like open, self-maintained, trauma, swelling, burns.
Breathing: describe breathing characteristics like rhythm, depth, and sounds.
Circulation: describe circulation characteristics like color, temperature, and presence of hives.
Pulses: describe pulse characteristics like rhythm, strength, and rate.
Description of Hemorrhage: describe hemorrhage characteristics like arterial, venous, active, or dried blood.
HEENT: describe any specific findings for each area, highlighting any trauma.
Neck/Back: describe any deformities, step-offs, or trauma.

RX (Treatment)

Include primary and secondary treatments, vitals, procedures performed, and EKG interpretation if performed.

Transport

Unit used and transport code: Code 1 or Code 3.
If fire department personnel ride in or transports: document vitals, procedures, any changes in patient condition, trauma alert, STEMI alert, stroke alert, and sepsis alert.

Destination

Hospital patient was taken to, the provider and room patient was transferred to.

Exceptions:

Any factors that prevented or interfered with patient care, including delays in treatment or transport.

Approved Medical Abbreviations

Provided as a reference list of abbreviations used in documentation.

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Description

This quiz covers the essential documentation practices required for patient care reports. It includes topics on medication administration, monitoring vital signs, and handling patient refusals. Test your knowledge on completing and reviewing patient care reports in accordance with established protocols.