EMS Documentation, Communication, Legal Issues, and Medical Terminology

Vocabulary flashcards generated from EMS transcript covering documentation, communication, consent, legal issues, safety, infection control, medical terminology, and systems.

Patient Care Report (PCR)

A legal document that records the assessment, care, treatment, and disposition of a patient.

Characteristics of a Good PCR

It should be accurate, objective, complete, concise, organized, timely, and legible.

Objective Information

Information that can be directly observed, measured, or verified by the EMS provider.

Subjective Information

Information reported by the patient or another person that cannot be directly measured by the provider.

Paper Record Error Correction

Draw a single line through the error, write the correct information, and initial/date it; never erase or obscure the original entry.

Electronic PCR Error Correction

Follow the system's correction or addendum procedure and never alter information in a way that hides the original entry.

Proper Anatomical Terminology

Precise, standardized communication used in EMS documentation to reduce misunderstandings about a patient's condition or injuries.

Open-Ended Question

A question that encourages the patient to provide more information rather than answering only yes or no.

Closed-Ended Question

A question that usually requires a short or specific answer, such as yes/no or a specific fact.

Therapeutic Communication

Communication techniques used to establish trust, gather information, reduce anxiety, and support the patient.

Active Listening

Paying close attention to what the patient says and demonstrating that you understand their concerns.

Consent

Permission given by a patient for EMS providers to assess or treat them.

Expressed Consent

Consent that is clearly communicated verbally or through actions.

Implied Consent

Consent assumed when a patient is unable to communicate and immediate treatment is necessary to prevent death or serious harm.

Informed Consent

Consent given after the patient receives enough information about the proposed treatment, risks, benefits, and alternatives to make an informed decision.

Patient Refusal

When a patient with decision-making capacity declines assessment, treatment, or transportation.

Decision-Making Capacity

The patient's ability to understand relevant information, appreciate the consequences, reason about options, and communicate a choice.

Duty to Act

A legal obligation to provide care when an EMS provider is required to respond and has accepted responsibility according to applicable law and policy.

Confidentiality

Protecting a patient's private health information from unauthorized disclosure.

Mandatory Reporting

A legal requirement to report certain situations, such as suspected abuse or neglect, to the appropriate authorities.

Neglect

Failure to provide necessary care, supervision, food, shelter, medical care, or other basic needs.

Advance Directive

A legal document that communicates a person's wishes about future medical treatment if they become unable to make decisions.

DNR Order

A valid medical order directing healthcare providers not to perform CPR if the patient's heart or breathing stops.

Scope of Practice

The procedures and responsibilities an EMS provider is legally authorized and trained to perform.

Scene Safety

The first priority at any EMS scene, requiring providers to look for hazards before approaching.

Exit Route

A clear path maintained by EMS providers to quickly move away if a situation becomes dangerous.

Burnout

A state of physical and emotional exhaustion that can result from prolonged occupational stress.

Standard Precautions

Infection-control practices used with every patient because blood and certain body fluids may contain infectious organisms.

BSI

Body Substance Isolation, an approach that treats potentially infectious body substances as if they are contaminated.

PPE

Personal protective equipment, such as gloves, eye protection, masks, and gowns.

Cross-Contamination

The transfer of infectious material from one person, object, or surface to another.

Anatomical Position

Standing upright, facing forward, arms at the sides, with palms facing forward.

Superior

Toward the head or above another structure.

Inferior

Away from the head or below another structure.

Anterior

Toward the front of the body.

Posterior

Toward the back of the body.

Medial

Toward the body's midline.

Lateral

Away from the body's midline.

Proximal

Closer to the point of attachment or origin of a body part.

Distal

Farther from the point of attachment or origin of a body part.

Midline

An imaginary vertical line dividing the body into right and left halves.

Bilateral

Relating to both sides of the body.

Unilateral

Relating to one side of the body.

Bradycardia

An abnormally slow heart rate.

Tachycardia

An abnormally fast heart rate.

Prefix "hypo-"

Below, under, or less than normal.

Prefix "hyper-"

Above, excessive, or greater than normal.

Suffix "-itis"

Inflammation.

Suffix "-ectomy"

Surgical removal.

Root "cardio-"

Refers to the heart.

Root "neuro-"

Refers to the nervous system or nerves.

Quality Improvement (QI)

A systematic process used to evaluate and improve the quality and effectiveness of patient care.

Patient Advocacy

Protecting and supporting the patient's rights, needs, preferences, and best interests.