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RequiredDocumentationona DeathScene/FailedResuscitation Policy: A patient care report will be filled out as completely as possible when a crew is called to an emergency scene where someone is deceased.
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How to fill out a patient care report
How to fill out a patient care report
01
Gather all necessary information about the patient, including their personal details, medical history, current condition, and any treatments provided.
02
Start by documenting the patient's chief complaint or reason for seeking care. Include any relevant details provided by the patient or any witnesses.
03
Record vital signs such as heart rate, blood pressure, respiratory rate, and temperature. Include any fluctuations or abnormalities observed.
04
Document a thorough physical assessment of the patient's body systems. Include any notable findings or abnormalities.
05
Describe any interventions or treatments provided to the patient. Include the time, dosage, and route of administration.
06
Include any medications given to the patient, along with the dosage, route, and time administered.
07
Document any changes in the patient's condition or incidents that occurred during the care.
08
Include any instructions or recommendations given to the patient or their caregiver.
09
Sign and date the patient care report to verify its accuracy.
10
Submit the completed patient care report to the appropriate healthcare personnel or agency.
Who needs a patient care report?
01
Patient care reports are needed by healthcare professionals, such as doctors, nurses, paramedics, and emergency medical technicians, who provide medical care to patients.
02
Healthcare facilities, such as hospitals, clinics, and ambulance services, require patient care reports for documentation and legal purposes.
03
Insurance companies and regulatory agencies may also request patient care reports to review the quality and appropriateness of care provided.
04
Researchers and educators may use patient care reports for study purposes and training future healthcare professionals.
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