Communications and Documentation - Chapter 4

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5 Terms

1
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CHART method

chif complaint, history and physical examination, assessment, treatment and transport

2
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SOAP

subjective, objective, assessment, plan

3
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SAFR (for health information exchange

search, alert, file, reconcile

4
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standing orders

written documents that have been signed by the EMS system’s medical director

5
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patient care report

legal document used to record all patient care activities