COPR EMR cheat sheet

Consent requires four elements: the patient must be competent, adequately informed, give consent voluntarily, and be of legal age or an emancipated/emergent exception applies.

Informed consent means explaining the assessment, proposed treatment, expected effects, and the right to refuse before proceeding.

Expressed consent is given verbally or by gesture; implied consent is assumed for a life-threatening emergency when the patient cannot respond.

A minor's consent for emergency treatment is generally implied; for non-emergency care, follow local legislation and seek a guardian.

Refusal must be documented: the patient is competent, informed of risks, and signs a refusal form; if they lack capacity, treat under implied consent and involve medical oversight.

Confidentiality: patient information is shared only on a need-to-know basis for care, and disclosure follows privacy legislation and mandatory reporting rules.

Scope of practice is defined by provincial/territorial legislation, employer policy, and medical oversight; acting outside it creates legal and safety risk.

Negligence requires four elements: a duty to act, a breach of the standard of care, causation, and damages.

Abandonment occurs when care is discontinued without ensuring an equal or higher level of care continues; handover to a receiving provider prevents it.

Primary survey sequence: scene safety, mechanism of injury/nature of illness, primary assessment (ABCs plus life threats), then secondary assessment.

Level of consciousness is assessed with AVPU: Alert, responds to Verbal stimulus, responds to Painful stimulus, Unresponsive.

The Glasgow Coma Scale scores eye (1-4), verbal (1-5), and motor (1-6) responses; total ranges 3 to 15.

Vital sign baselines for adults: respiratory rate 12-20/min, heart rate 60-100/min, systolic BP about 90-140 mmHg, SpO2 94-100% on room air.

Sample history: Signs and symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading to the injury or illness.

OPQRST for pain: Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Time.

Focused assessment targets the chief complaint and related body systems; a rapid full-body scan is used for trauma or an unreliable patient.

Reassess the patient after every intervention and at least every 5 minutes for unstable and every 15 minutes for stable patients.

Open the airway with a head-tilt/chin-lift for a medical patient without suspected spinal injury; use a jaw-thrust if spinal injury is suspected.

Suctioning is limited to about 10-15 seconds per attempt and should be preceded by adequate preoxygenation.

An oropharyngeal airway is only for patients without a gag reflex; a nasopharyngeal airway may be used when a gag reflex is present.

Bag-valve-mask ventilation targets about 1 breath every 5-6 seconds for adults (10-12/min) and delivers roughly 500-600 mL per breath.

Signs of adequate ventilation: visible chest rise, improving color, and rising SpO2; signs of inadequate ventilation include absent chest rise and gastric distension.

For an adult with a pulse but inadequate breathing, provide rescue breaths at about 10-12 per minute; if no pulse, begin CPR with a compression-to-ventilation ratio of 30:2.

Oxygen therapy: titrate to SpO2 of 94-98% for most patients; use a nasal cannula at 1-6 L/min, a simple mask at 6-10 L/min, and a non-rebreather at 10-15 L/min.

A foreign-body airway obstruction in a conscious adult is managed with abdominal thrusts; an unconscious patient receives CPR and airway checks.

High-quality CPR: compress the adult chest at least 5 cm (2 inches) deep, at a rate of 100-120/min, with full recoil and minimal interruptions.

Adult single-rescuer CPR uses a 30:2 compression-to-ventilation ratio; compression-only CPR is acceptable when a rescuer cannot or will not ventilate.

An AED is applied as soon as available: power on, attach pads, clear the patient during analysis and shock delivery, then immediately resume compressions.

AED pad placement: one pad below the right clavicle and one on the left lateral chest, or per the device diagram; dry the chest and remove medication patches.

Do not defibrillate a patient in a wet environment or with a nitroglycerin patch in the pad path; move the patient and remove the patch first.

Pediatric AED use: use pediatric pads or an attenuator when available; if not, an adult AED may be used per local protocol.

Signs of shock: rapid weak pulse, pale/cool/clammy skin, altered mental status, and falling blood pressure; treat with oxygen, positioning, warmth, and rapid transport.

Severe external bleeding is controlled with direct pressure, then a tourniquet applied proximal to the wound if pressure fails.

Hypoglycemia presents with altered mental status, sweating, and tremor; if the patient can swallow safely, give oral glucose, otherwise follow protocol for parenteral options.

Stroke recognition uses a rapid screen such as FAST (Face, Arms, Speech, Time); note the time of symptom onset for reperfusion decisions.

For suspected acute coronary syndrome, assist the patient with prescribed nitroglycerin and aspirin per protocol; withhold nitroglycerin if systolic BP is below about 90-100 mmHg.

Anaphylaxis: administer epinephrine via auto-injector (adult dose 0.3 mg IM) into the anterolateral thigh, then provide oxygen and transport.

Asthma: assist with the patient's prescribed bronchodilator inhaler, provide oxygen, and monitor for worsening respiratory effort.

Seizure care: protect the patient from injury, do not restrain or place objects in the mouth, and time the seizure; transport if it lasts over 5 minutes or recurs.

Opioid overdose presents with depressed respirations and pinpoint pupils; naloxone is given per protocol with ventilation support.

The five medication rights: right patient, right medication, right dose, right route, and right time; document the effect after administration.

Spinal motion restriction is indicated for a significant mechanism with altered mental status, midline tenderness, neurologic deficit, or distracting injury.

Splint a suspected fracture in the position found, check distal circulation, sensation, and movement before and after splinting.

Burns: cool with clean water for about 10-20 minutes, remove jewelry and loose clothing, cover with a dry sterile dressing, and estimate extent with the rule of nines.

Rule of nines for adults: each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, head 9%, perineum 1%.

Head injury: maintain oxygenation and blood pressure, avoid hypoxia, and monitor for decreasing level of consciousness and unequal pupils.

Heat stroke is a core temperature above about 40°C with altered mental status; begin active cooling immediately and transport.

Hypothermia: handle gently, remove wet clothing, insulate, and avoid rough movement; rewarm the trunk before the extremities.

Chest injury with a sucking wound is covered with an occlusive dressing, and a flail chest is supported with oxygen and positive-pressure ventilation as needed.

Normal newborn delivery: support the head, check for a nuchal cord, dry and warm the infant, and stimulate breathing; assess APGAR at 1 and 5 minutes.

Newborn resuscitation begins with warming, positioning, drying, and stimulation; if breathing remains inadequate, provide positive-pressure ventilation.

Pediatric vital signs vary with age: infants have higher heart and respiratory rates than adults, and hypotension is a late sign of decompensation.

Pediatric CPR uses a compression depth of about one-third of the chest diameter, with a 30:2 ratio for single rescuers and 15:2 for two rescuers.

For a pregnant patient, place her in the left lateral position or manually displace the uterus to relieve compression of the inferior vena cava.

Postpartum hemorrhage is managed with fundal massage, oxygen, and rapid transport while monitoring for shock.

Elderly patients may have atypical presentations of illness and are more vulnerable to medication interactions and injury from falls.

Bariatric patients require additional personnel and equipment planning for safe lifting, airway management, and transport.

Scene safety is assessed before every call and reassessed continuously; do not enter an unsecured scene without appropriate resources.

Radio communication uses clear, brief, standardized language; identify the unit, state the situation, and confirm receipt of orders.

Patient report format includes the patient's age and sex, chief complaint, relevant history, vital signs, interventions, and response to treatment.

Documentation must be objective, accurate, and timely, recording the assessment findings, interventions, times, and the patient's response.

Body substance isolation: gloves for all patient contact, eye protection for splash risk, and a mask or N95 for airborne precautions.

Lifting technique uses a wide base, bent knees, and load close to the body; team lifting is used for heavy loads.

Triage in a multiple-casualty incident sorts patients by priority: immediate, delayed, minimal, and expectant.

Incident command establishes a single incident commander with defined roles such as triage, treatment, and transport.

Therapeutic communication uses open-ended questions, active listening, and reflection to build rapport and gather information.

Speak to the patient at eye level, use their name, and explain procedures before performing them.

When a patient is agitated, lower your voice, reduce environmental stimulation, and maintain a safe distance.

Cultural competence means adapting communication and care to the patient's beliefs, language, and health practices.

A language interpreter should be used rather than a family member for critical information when possible.

Breaking bad news uses clear, simple language, acknowledges emotion, and avoids false reassurance.

Document a patient's expressed wishes, including do-not-resuscitate orders, and follow local protocol and legislation.

Handover to receiving staff should be structured, concise, and include any changes since the last assessment.

Personal protective equipment is selected based on the anticipated exposure risk, including gloves, gown, mask, and eye protection.

Immunization and post-exposure protocols reduce the risk of occupational transmission of bloodborne pathogens.

Critical incident stress may appear as sleep disturbance, irritability, or intrusive thoughts; peer support and employee assistance resources are available.

Fit testing and seal checks are required for N95 respirators before use in an airborne precaution setting.

Fatigue impairs judgment and reaction time; report impairment and follow fatigue-management policies.

Continuing education and skills maintenance are required to keep certification and competence current.

Scope of practice changes require appropriate training and authorization before performing new skills.

Ethical practice includes honesty in documentation, avoiding conflicts of interest, and reporting unsafe practice.