Term
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Definition
| C.chief complaint H.History (sample) E.exam A. assessment T.treatment E. evaluation D. disposition(transfer of patient) |
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Term
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Definition
S.subjective(patient must tell you) O. objective(you identify in the patient) A. assessment(general idea you form about patient condition) P. plan(plan of action) |
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Term
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Definition
C.chief complaint H. history A.assessment R.Rx(treatment that was provided) T. transport |
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Term
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Definition
| draw a single horizontal line through the error initial it write the correct information next to it |
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Term
| legal uses of documintation |
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Definition
| a run which you were involved in may have been a result of a crime or the incident may led to a lawsuit. in ethier case you may have to appear in court as a witnes |
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Term
| communicating with the recieving facility |
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Definition
~units identification and levfel of service ~age and sex ~Chief complaint ~brief patient history of present illness moi/noi ~major past illness ~patient mental status ~baseline vitals ~Pertinent findings ~Description of emergency medical care ~patient response to emergency care ~estimated time of arrivial |
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Term
| communicating with medical direction |
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Definition
units identification level of service ~age and sex ~chief complaint ~brief pertient history of present history scene assessment |
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