St. Johns Fire District Patient Care Guidelines

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Questions and Answers

What is the primary focus of the Level 1 review?

Emergency response time

Assessment of equipment functionality

Training needs of the EMTs and Paramedics

Compliance with STJFD Standard Operating Guideline 200.07 (correct)

Who assigns the Level 1 reviews?

The Medical Director

The Fire Chief

The Medical Battalion Chief (correct)

The EMT training officer

When will a review be elevated to Level 2?

If training needs are identified

When the Medical Director is involved

When infractions or deviations from protocol are found (correct)

If it identifies only documentation errors

What happens if a Level 2 review is not resolved?

It is elevated to Level 3 Signup and view all the answers

Who conducts the Level 3 reviews?

Members of Command Staff with Medical Director consultation Signup and view all the answers

Within what time frame must Level 1 reviews be completed?

14 days Signup and view all the answers

What type of errors does Level 2 address?

Infractions or deviations from protocol Signup and view all the answers

What role does the Medical Battalion Chief play in the review process?

Assigns Level 1 reviews and conducts Level 2 reviews Signup and view all the answers

What is communicated to the member being reviewed after a Level 3 review?

The results and required actions Signup and view all the answers

What is one reason a report might undergo a Level 1 review?

Specific priorities identified by leadership Signup and view all the answers

What is the primary purpose of the St. John's Fire District's policy on patient care reporting?

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

Which software has been approved for electronic patient care reporting (ePCR) by the St. John's Fire District?

ImageTrend 'Field' software Signup and view all the answers

How soon must ePCRs be completed after the incident notification?

Within twenty-four hours Signup and view all the answers

What is a key element that must be documented for each patient encounter?

Vital signs Signup and view all the answers

What format should the ePCR narrative follow?

Chronological format Signup and view all the answers

Which of the following is NOT a component to be included in the ePCR narrative?

Personal opinions on patient condition Signup and view all the answers

Who needs to ensure that all required fields in the reporting software are completed?

The emergency medical technician (EMT) or Paramedic Signup and view all the answers

What should the 'Dispatched To' section of the narrative describe?

The initial call for service and units dispatched Signup and view all the answers

Why is it imperative that the information reported in ePCRs is accurate?

It becomes part of the patient's medical record Signup and view all the answers

What should be included in addition to vital signs in the ePCR?

Pertinent information related to the medical incident Signup and view all the answers

What must the EMT ensure when a patient refuses care?

The STJFD patient refusal form is completed and signed Signup and view all the answers

What disposition should be selected in the ImageTrend NEMSIS 3.5 system for a patient refusal?

Refusal Signup and view all the answers

If the report writer cannot scan and upload the refusal form, what should they do?

Mail the form to the Chief Medical Officer Signup and view all the answers

Who is responsible for ensuring that all patient care reports are completed?

The company officers Signup and view all the answers

Which incident does NOT require a Level 1 review?

Injury from a fall Signup and view all the answers

Which of the following is a base activator for a Level 1 review?

Insertion of any airway adjuncts Signup and view all the answers

What format should the signed refusal form be uploaded into the ePCR?

.pdf Signup and view all the answers

What should be documented as the chief complaint?

The patient's expressed chief complaint and any secondary complaints Signup and view all the answers

Who is responsible for initiating a Level 1 review?

The Medical Battalion Chief Signup and view all the answers

What must be documented in the ePCR after a patient refuses care?

The patient's orientation and education regarding refusal Signup and view all the answers

What does the primary assessment include?

First impression and airway status Signup and view all the answers

In case of a patient refusal, who oversees the quality review process?

The Medical Battalion Chief and command staff Signup and view all the answers

What is included in the ongoing assessment section?

Response to treatments and medications Signup and view all the answers

Which of the following is true about airway placement confirmation?

It must be confirmed with chest rise and lung sounds Signup and view all the answers

What should be documented if a patient refuses treatment?

Findings as for any other patient and a refusal form Signup and view all the answers

What information must be included when documenting patient turnover?

Unit number of transporting EMS agency and relevant details Signup and view all the answers

What is required when using an automatic external defibrillator (AED)?

Document that AED data needs downloading Signup and view all the answers

Which of the following is part of the secondary or focused assessment?

Detailed physical exam and pertinent negatives Signup and view all the answers

What must be documented regarding treatments provided?

All treatments provided and vital signs outside normal limits Signup and view all the answers

Which statement about capnography documentation is correct?

It must be documented if the device was present or used Signup and view all the answers

Study Notes

Purpose and Objective

Establishes minimum requirements for patient care reporting and quality review at St. John's Fire District (STJFD).
Aims for a standardized process for documenting patient care and conducting quality assurance reviews.

Patient Care Reporting

Utilizes electronic patient care reporting (ePCR) software for documentation of all patient encounters.
Approved software: ImageTrend "Field," compliant with DHEC Standard 61-7.
ePCRs must be completed within 24 hours of incident notification.
Requires accurate completion of required fields and documentation of vital signs for each patient.

ePCR Narrative

Serves as detailed documentation of patient treatment, covering:
- Dispatched To: Initial call details and units dispatched.
- Upon Arrival: Description of incident scene.
- Chief Complaint: Document patient’s main complaint and any secondary complaints.
- Primary Assessment: Initial impressions including consciousness, airway, breathing, circulation, and history.
- Secondary Assessment: Detailed physical exam and pertinent negatives.
- Treatments: Document treatments provided and abnormal vitals.
- Ongoing Assessment: Patient's response to treatments and additional assessments.
- Notes: Information on patient turnover to transporting agency, including transport unit number and relevant transfer details.

Airway Management and Patient Refusal

Confirm airway placement using chest rise and lung sounds.
If a patient refuses treatment, complete a STJFD refusal form and select "refusal" in ePCR system.
Signed refusal forms must be uploaded into the ePCR in PDF format.

Notifications

Notify the STJFD Medical Battalion Chief anytime an AED is used to facilitate data download for record-keeping.

Medical Quality Assurance and Improvement

The quality improvement program aims for professional and systematic emergency medical care delivery.
Responsibility for thorough reviews lies with the Medical Battalion Chief, command staff, and Medical Director.
Company officers must ensure completion and accuracy of ePCRs for their personnel.

Levels of Quality Review

Level 1 Review: Initiated for significant incidents (e.g., cardiac arrest, airway adjunct insertion). Must be completed within 14 days by designated EMTs or Paramedics.
Level 2 Review: Conducted if infractions or deviations from protocol are identified during Level 1. Managed by the Medical Battalion Chief.
Level 3 Review: Activated when Level 2 findings require further action, reviewed by Command Staff and the Medical Director.

Required Information in Patient Care Reports

All patient care reports must include complete patient evaluations, treatments, and the rationale behind medical decisions.
Any deviation from established protocols during patient care must be documented accurately to ensure compliance with quality standards.

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Description

This quiz covers the standard operating guidelines for patient care reporting and quality review established by the St. John's Fire District. It focuses on the minimum requirements and objectives to ensure effective and standardized processes in patient care reporting. Learn the essential elements that contribute to quality assurance in emergency services.