Ch. 4 "Documentation" Terms and definitions

                                 

• Prehopital care report: The type of PCR report varies widely among EMS systems and states; however, the information collected is basically the same.The documentation you generate and report via the PCR and other special reporting forms is important for other reasons as well.
• minimum data: The DOT created a standard for data that will help the educational out look on the future of EMS's. This minimum set is; chief complaint, level of responsiveness, skin perfusion for patients less than 6 years old, skin color, temperature and condition, pulse rate, respiratory rate and effort, patient demographics (sex, age, race, weight).
• triage tag: the record that is attached to the patient for gathering all the information.
• SOAP:  This mnemonic SOAP stands for subjective, objective, assessment, and plan.  
•          subjective-refers to the information a patient must tell you, how they are feeling etc.
•          objective-refers to the information you identify in the physical examination through inspection,        palpation, and auscultation.
•          assessment-refers to the field assessment, the general idea you form based on the subjective and objective assessments along with scene assessment and other information provided by bystanders or family.
•           plan-refers to the plan of action and the emergency care provided to the patient.

• pertinent negatives: In questioning a patient be aware of pertinent negatives. this refers to the signs and symptoms that might be expected, based on chief complaint, but that the patient denies having.
• administration data: Includes administration information as well as, the EMS unit number, names of crew members and their levels of certification, the address to which the unit was dispatched.