ppt课件-documentation e m s c h a r t s- chester first aid squad（文档e m s c h r t s -切斯特急救队伍）.pptVIP

下载本文档

3
0
约4.22千字
约 19页
2017-01-25 发布于四川
举报
版权申诉

ppt课件-documentation e m s c h a r t s- chester first aid squad（文档e m s c h r t s -切斯特急救队伍）.ppt

1、原创力文档（book118）网站文档一经付费（服务费），不意味着购买了该文档的版权，仅供个人/单位学习、研究之用，不得用于商业用途，未经授权，严禁复制、发行、汇编、翻译或者网络传播等，侵权必究。。
2、本站所有内容均由合作方或网友上传，本站不对文档的完整性、权威性及其观点立场正确性做任何保证或承诺！文档内容仅供研究参考，付费前请自行鉴别。如您付费，意味着您自己接受本站规则且自行承担风险，本站不退款、不进行额外附加服务；查看《如何避免下载的几个坑》。如果您已付费下载过本站文档，您可以点击这里二次下载。
3、如文档侵犯商业秘密、侵犯著作权、侵犯人身权等，请点击“版权申诉”（推荐），也可以打举报电话：400-050-0827(电话支持时间：9:00-18:30)。
4、该文档为VIP文档，如果想要下载，成为VIP会员后，下载免费。
5、成为VIP后，下载本文档将扣除1次下载权益。下载后，不支持退款、换文档。如有疑问请联系我们。
6、成为VIP后，您将拥有八大权益，权益包括：VIP文档下载权益、阅读免打扰、文档格式转换、高级专利检索、专属身份标志、高级客服、多端互通、版权登记。
7、VIP文档为合作方或网友上传，每下载1次，网站将根据用户上传文档的质量评分、类型等，对文档贡献者给予高额补贴、流量扶持。如果你也想贡献VIP文档。上传文档

Documentation / EMSCHARTS What is documentation? A permanent legal document which provides a comprehensive account of information about the individual’s health care status. Why document? Clinical Legal document which you may have to defend in court one day, years from incident Data and statistics Medical record which must be treated confidentially, as defined by HIPPA regulations Education Quality Management Guidelines If it is not written down, it was not done. If it was not done, do not write it down. Characteristics of Strong Documentation Complete Clear Concise Accurate (including spelling) Objective Timely Objective vs. subjective Objective- intended to be unbiased Subjective- usually based on fact, but it is someone’s interpretation of a fact Ex: a. The patient was in a lot of pain. b. The patient had mid-sternal chest pain which radiated into his back 8/10, sharp, consistent, negative increase in pain on palpation. Approaches to Narrative (CHART System) CHART- Chief Complaint, History, Assessment, Rx(Treatment), Transport Other options: SOAP (Subjective findings, Objective findings, Assessment, Plan) Chief complaint and history (C,H)- What you are told Chief Complaint History of Present Illness: OPQRST Past Medical History: SAMPLE What is a chief complaint? “Reason EMS has been called, usually recorded in patient’s own words” “Some cases the patient’s chief complaint is different from the reason EMS was called” Source: Emergency Medical Technician EMT in Action, 2nd Edition, Barbara Aehlert, page 306, Published by McGraw-Hill, New York, NY, 2011 Assessment (A)- What you see/feel/hear Trauma -pt. appearance, surroundings, position -head, nose, eyes, ear, throat -neck -chest -abdomen, pelvis -extremities Cardiopulmonary -pt. appearance, surroundings, position -neck- jugular veins, trach deviation -chest – lung sounds, respiratory rate -extremities- edema, pms -other- oxygen sat level AMS -pt. appearance, surroundings, position -mental status (AVPU,