Tag Archives | documentation

Communications | Part Four

Documentation Documentation: the process of recording patient information Proper documentation includes: Record of the scene Patient’s CC Patient’s condition Nature and extent of emergency care given Changes in the patient’s condition Patient’s name, address, age and sex Administrative information ie disposition of the call Reasons for Documentation #1 Continuation of care, supplying vital info to […]

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History Taking | Part One

History Taking – Part One History comes from a variety of sources: Patient Family Friends, Bystanders Law Enforcement Weigh reliability of what they are telling you based on: Mental Status, memory, whether they trust you whether they have something to gain Techniques of History Taking Setting the stage: needs to be the proper environment, put […]

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