An intoxicated patient will not leave the oxygen mask on. You are aware that the acronym FACTUAL-OEC outlines the characteristics of good report writing. Based on these guidelines how would this best be documented on the prehospital care report (PCR)?
a. The patient is intoxicated and will not cooperate with oxygen therapy.
b. The patient continually removes the oxygen mask despite continued reapplication.
c. The patient will not cooperate with care provided by the ski patrol.
d. The patient appears to be in a drunk-like state and will not cooperate with care provided by the ski patrol.
Question 2
Two days after a call, you realize that you forgot to document that you checked a patient's pupils before the patient refused further treatment and signed a refusal form. Which of the following actions is your best course of action?
a. Complete a new refusal form and include the additional information.
b. Add an addendum to the report that contains the correct information, the current date, and your signature.
c. Report the error to your patrol director and have him/her take care of it.
d. Don't worry about it because it did not seem to matter to the patient.
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National Patient Safety Goals for Acute-Care Hospitals