The QI manager calls your partner into his office after your shift. He pulls out his EMS report on a call he ran last month on a 45-year-old driver of a single-vehicle motor vehicle collision. There were several empty beer cans in the patient's vehicle and the EMT detected an odor of alcoholic beverages on the patient's breath. The QI manager, however, critiques your partner about calling the patient an alcoholic and giving opinions in the report. He tells your partner to never write opinions in the EMS report. Your partner is confused because he is sure the patient was drunk, and he was actually arrested for suspicion of driving while intoxicated. Your partner believes his assessment is supported by facts and not just his opinion. How can you help your partner understand the QI manager's concerns?
A) The QI manager is afraid the patient will sue the EMS service for libel.
B) Documenting that the patient is an alcoholic gives an incorrect opinion of the patient that is not supported by facts, and could negatively influence other medical providers.
C) The patient is assumed to be innocent until proven guilty. He is not an alcoholic until he is convicted of drinking and driving by a court of law.
D) Calling the patient an alcoholic is not polite, even if it is true.
Question 2
Which of the following is an indicator that a patient's nervous system has been impaired?
A) General weakness B) Changes in pupil dilation
C) Hearing disturbances D) All of the above
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Example of a day sheet report.
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Exploring Microsoft Office 2013, Volume 2, First Canadian Edition