Exams Documentation Communication IHERN Peds Autism Geriatrics Clinical Rotation Homework...
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Transcript of Exams Documentation Communication IHERN Peds Autism Geriatrics Clinical Rotation Homework...
![Page 1: Exams Documentation Communication IHERN Peds Autism Geriatrics Clinical Rotation Homework assignment.](https://reader035.fdocuments.us/reader035/viewer/2022081907/551516e7550346a80c8b5e1e/html5/thumbnails/1.jpg)
![Page 2: Exams Documentation Communication IHERN Peds Autism Geriatrics Clinical Rotation Homework assignment.](https://reader035.fdocuments.us/reader035/viewer/2022081907/551516e7550346a80c8b5e1e/html5/thumbnails/2.jpg)
• Exams• Documentation• Communication
IHERN• Peds
Autism• Geriatrics• Clinical Rotation• Homework assignment
![Page 3: Exams Documentation Communication IHERN Peds Autism Geriatrics Clinical Rotation Homework assignment.](https://reader035.fdocuments.us/reader035/viewer/2022081907/551516e7550346a80c8b5e1e/html5/thumbnails/3.jpg)
DOCUMENTATION
![Page 4: Exams Documentation Communication IHERN Peds Autism Geriatrics Clinical Rotation Homework assignment.](https://reader035.fdocuments.us/reader035/viewer/2022081907/551516e7550346a80c8b5e1e/html5/thumbnails/4.jpg)
Pre-hospital Care Report
• Computerized
direct data entry
electronic clip boards
pen based computers
PDA
![Page 5: Exams Documentation Communication IHERN Peds Autism Geriatrics Clinical Rotation Homework assignment.](https://reader035.fdocuments.us/reader035/viewer/2022081907/551516e7550346a80c8b5e1e/html5/thumbnails/5.jpg)
Complete report while still fresh in your mind
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Patient Care Reports• Become permanent part of record• Legal document• Administration
insurance and billing info• Education and research• QI
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Documentation
• Confidentiality
Health Insurance Portability and Accountability Act
• Patient Refusal
![Page 8: Exams Documentation Communication IHERN Peds Autism Geriatrics Clinical Rotation Homework assignment.](https://reader035.fdocuments.us/reader035/viewer/2022081907/551516e7550346a80c8b5e1e/html5/thumbnails/8.jpg)
Falsification• Two types of errors
OmissionCommission
actions that were wrong or improper. Document thoroughly and contact medical direction.
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• If it’s not documented, it wasn’t done
• If it’s not done, don’t document it
• Repercussions
suspension or revocation of cert.
false impression of pt. care is passed on
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Correcting Errors
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Special situations
• Multiple-casualty incidents
use triage tags
![Page 12: Exams Documentation Communication IHERN Peds Autism Geriatrics Clinical Rotation Homework assignment.](https://reader035.fdocuments.us/reader035/viewer/2022081907/551516e7550346a80c8b5e1e/html5/thumbnails/12.jpg)
Special situation reports• Exposure to infectious disease• Injury to self or another EMT• Hazardous or unsafe scenes of which
other crews should be alerted• Referral to Social Service agencies
remain accurate and objective
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