Effective Communications and Documentation in Emergency Medical Services

1. 9: Communications and Documentation

2. Cognitive Objectives (1 of 5) 3-7.1 List proper methods of initiating and terminating a radio call. 3-7.2 State proper sequence for delivery of patient information. 3-7.3 Explain the importance of effective communication of patient information in the verbal report. 3-7.4 Identify the essential components of the verbal report.

3. Cognitive Objectives (2 of 5) 3-7.5 Describe attributes for increasing effectiveness and efficiency of verbal communications. 3-7.6 State legal aspects to consider in verbal communication. 3-7.7 Discuss the communication skills that should be used to interact with the patient.

4. Cognitive Objectives (3 of 5) 3-7.8 Discuss the communication skills that should be used to interact with the family, bystanders, and individuals from other agencies while providing patient care and hospital personnel, and the difference between skills used to interact with the patient and those used to interact with others. 3-7.9 List the correct radio procedures in the following phases of a typical call: to the scene, at the scene, to the facility, at the facility, to the station, at the station.

5. Cognitive Objectives (4 of 5) 3-8.1 Explain the components of the written report and list the information that should be included on the written report. 3-8.2 Identify the various sections of the written report. 3-8.3 Describe what information is required in each section of the prehospital care report and how it should be entered. 3-8.4 Define the special considerations concerning patient refusal.

6. Cognitive Objectives (5 of 5) 3-8.5 Describe the legal implications associated with the written report. 3-8.6 Discuss all state and/or local record and reporting requirements.

7. Affective Objectives 3-7.10 Explain the rationale for providing efficient and effective radio communications and patient reports. 3-8.7 Explain the rationale for patient care documentation. 3-8.8 Explain the rationale for the EMS system gathering data. 3-8.9 Explain the rationale for using medical terminology correctly.

8. Psychomotor Objectives 3-7.11 Perform a simulated, organized, concise radio transmission. 3-7.12 Perform an organized, concise patient report that would be given to the staff at a receiving facility. 3-7.13 Perform a brief, organized report that would be given to an ALS provider arriving at an incident scene at which the EMT-B was already providing care. 3-8.11 Practice completing a prehospital care report.

9. Communications and Documentation • Essential components of prehospital care: • Verbal communications are vital. • Adequate reporting and accurate records ensure continuity of patient care. • Reporting and record keeping are essential aspects of patient care.

10. Base Station Radios • Transmitter and receiver located in a fixed place • Power of 100 watts or more • A dedicated line (hot line) is always open. • Immediately “on” when you lift up the receiver

11. Mobile and Portable Radios • Mobile radios installed in vehicle • Range of 10 to 15 miles • Portable radios hand-held • Operate at 1 to 5 watts of power

12. Repeater-Based Systems • Receives radio messages and retransmits • A repeater is a base station able to receive low-power signals.

13. Digital Equipment • Some EMS systems use telemetry to send an ECG from the unit to the hospital. • Telemetry is the process of converting electronic signals into coded, audible signals. • Signals can be decoded by the hospital.

14. Cellular Telephones • Low-powered portable radios that communicate through interconnected repeater stations • Cellular telephones can be easily scanned.

15. Other • Simplex • Push-to-talk communication • Duplex • Simultaneous talk-listen • MED channels • Reserved for EMS

16. Communication Quality • Affected by power and location of antennas • Changes in location can affect quality of transmission • Check communication equipment at beginning of each shift.

17. FCC Duties • Allocate radio frequencies • License base stations and assign call signs. • Establish licensing standards and operating specifications • Establish limits on transmitter power output • Monitor radio operations

18. Dispatch Responsibilities • Screen and assign priorities • Select and alert appropriate units to respond • Dispatch and direct units to the location • Coordinate response with other agencies • Provide pre-arrival instructions to the caller

19. Information Receivedfrom Dispatch • Nature and severity of injury, illness, or incident • Location of incident • Number of patients • Responses by other agencies • Special information • Time dispatched

20. Communicating With Dispatch • Report any problems during run. • Advise of arrival. • Communicate scene size-up. • Keep communications brief. Insert EMTB9e Fig. 9-4.

21. CommunicatingWith Medical Control • Radio communications facilitate contact between providers and medical control. • Consult with medical control to: • Notify hospital of incoming patient. • Request advice or orders. • Advise hospital of special circumstances. • Organize your thoughts before transmitting.

22. Patient Report • Identification and level of services • Receiving hospital and ETA • Patient’s age and gender • Chief complaint • History of current problem • Physical findings • Summary of care given and patient response

23. Role of Medical Control • May be off-line or online • Guides treatment of patients • May have to contact directly for orders • Many variations from system to system

24. Calling Medical Control • Physician bases his or her instructions on report received from the EMT-B. • Never use codes while communicating. • Repeat all orders received. • Do not blindly follow an order that does not make sense to you.

25. Special Situations • Notify as early as possible. • Estimate the potential number of patients. • Identify special needs.

26. Standard Procedures and Protocols • Keep transmission brief. • Develop effective radio discipline. • Identify the called unit, followed by the calling unit. • “Dispatch, this is Medic One.”

27. Reporting Requirements • Acknowledge dispatch information. • Notify arrival at scene. • Notify departure from scene. • Notify arrival at hospital or facility. • Notify you are clear of the incident. • Notify arrival back in quarters.

28. Maintenance of Equipment • Radio equipment must be properly serviced. • Nonfunctioning equipment should be removed from service. • Backup plans should be in place in case of communication failure. • Standing orders: Written documents signed by the EMS system’s medical director.

29. Verbal Communication • Essential part of quality patient care • You must be able to find out what the patient needs and then tell others. • You are a vital link between the patient and the health care team.

30. Components of an Oral Report • Patient’s name, chief complaint, nature of illness, mechanism of injury • Summary of information from radio report • Any important history not given earlier • Patient’s response to treatment • The vital signs assessed • Any other helpful information

31. Communicating With Patients (1 of 2) • Make and keep eye contact. • Use the patient’s proper name. • Tell the patient the truth. • Use language the patient can understand. • Be careful of what you say about the patient to others.

32. Communicating With Patients (2 of 2) • Be aware of your body language. • Always speak slowly, clearly, and distinctly. • If the patient is hearing impaired, speak clearly and face him or her. • Allow time for the patient to answer questions. • Act and speak in a calm, confident manner.

33. Communicating With GeriatricPatients • Determine the person’s functional age. • Do not assume that an older patient is senile or confused. • Allow patient ample time to respond. • Watch for confusion, anxiety, or impaired hearing or vision. • Explain what is being done and why.

34. Communicating With Children • Children are aware of what is going on. • Allow people or objects that provide comfort to remain close. • Explain procedures to children truthfully. • Position yourself on their level.

35. Communicating With Hearing-Impaired Patients • Always assume that the patient has normal intelligence. • Make sure you have a paper and pen. • Face the patient and speak slowly, clearly and distinctly. • Never shout! • Learn simple phrases used in sign language.

36. Communicating With Vision-Impaired Patients • Ask the patient if he or she can see at all. • Explain all procedures as they are being performed. • If a guide dog is present, transport it also, if possible.

37. Communicating With Non-English-Speaking Patients • Use short, simple questions and answers. • Point to specific parts of the body as you ask questions. • Learn common words and phrases in the non-English languages used in your area.

38. Written Communication and Documentation Written Communication and Documentation

39. Minimum Data Set (1 of 2) • Patient information • Chief complaint • Mental status • Systolic BP (patients older than 3 years) • Capillary refill (patients younger than 6 years) • Skin color and temperature • Pulse • Respirations and effort

40. Minimum Data Set (2 of 2) • Time incident was reported • Time that EMS unit was notified • Time EMS unit arrived on scene • Time EMS unit left scene • Time EMS unit arrived at facility • Time that patient care was transferred

41. Functions of the PrehospitalCare Report • Prehospital care report serves six functions • Continuity of care • Legal documentation • Education • Administrative • Research • Evaluation and quality improvement

42. Types of Forms • Written forms • Computerized versions • Narrative sections of the form • Use only standard abbreviations. • Spell correctly. • Record time with assessment findings. • Report is considered confidential.

43. Reporting Errors • Do not write false statements on report. • If error made on report then: • Draw a single horizontal line through error. • Initial and date error. • Write the correct information .

44. Documenting Right of Refusal • Document assessment findings and care given. • Have the patient sign the form. • Have a witness sign the form. • Include a statement that you explained the possible consequences of refusing care to the patient.

45. Special Reporting Situations • Be familiar with required reporting in your jurisdiction, including: • Gunshot wounds • Animal bites • Certain infectious diseases • Suspected physical, sexual, or substance abuse • Multiple-casualty incidents (MCI)