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OKLAHOMA DEPARTMENT OF CORRECTIONS Emergency Care Record SRM 140117.01.48-Page 1 of 2 (R 6/11) (Medical Diagram of Injury) Chief Complaint: Onset: Location: Medical History: None Asthma CAD COPD CVA

How to fill out emergency care record

How to fill out emergency care record

1. Start by gathering all necessary information about the patient, such as their personal details, medical history, and emergency contact information.
2. Ensure that you have the appropriate emergency care record form or template to use. This can typically be obtained from the healthcare facility or organization involved.
3. Begin by accurately documenting the date and time of the emergency care event.
4. Record the chief complaint or reason for seeking emergency care, including any symptoms or injuries reported by the patient.
5. Document a detailed account of the patient's medical history, including any pre-existing conditions, allergies, and medications they are currently taking.
6. Record vital signs such as blood pressure, heart rate, temperature, and oxygen saturation.
7. Document any procedures or treatments performed during the emergency care, along with the date, time, and outcome of each intervention.
8. Make sure to note any medication administered to the patient, including the dosage, route of administration, and any potential side effects or adverse reactions.
9. Include any laboratory or diagnostic test results relevant to the emergency care event, such as X-ray reports or blood test findings.
10. Document the name and contact information of the healthcare professionals involved in providing the emergency care.
11. Sign and date the emergency care record to verify its authenticity and completeness.

Who needs emergency care record?

1. Anyone who receives emergency medical care may require an emergency care record.
2. This includes individuals who experience acute medical conditions, injuries, accidents, or sudden changes in their health status that require immediate medical attention.
3. Emergency care records are crucial for healthcare providers to accurately assess, diagnose, and treat patients in emergency situations.
4. They are also important for documenting the sequence of events and interventions undertaken during the emergency care, serving as a legal and administrative record.
5. Patients themselves may also benefit from having an emergency care record as it provides a comprehensive summary of their emergency medical treatment, which can be useful for future reference or when seeking ongoing medical care.

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What is emergency care record?

Emergency care record is a document that records the details of emergency medical treatment provided to a patient.

Who is required to file emergency care record?

Healthcare providers such as doctors, nurses, and paramedics are required to file emergency care records.

How to fill out emergency care record?

Emergency care records should be filled out with accurate and detailed information about the patient's condition, treatment received, and any medications administered.

What is the purpose of emergency care record?

The purpose of emergency care record is to document the care provided to a patient during an emergency situation for future reference and medical treatment planning.

What information must be reported on emergency care record?

Information such as patient's vital signs, medical history, allergies, medications, treatment received, and outcome of the emergency care must be reported on the emergency care record.