Communication and Documentation

1. 15 Communication and Documentation

2. Multimedia Directory Slide 21 Effective Communication Video

3. Topics • Communication Systems and Radio Communication • The Verbal Report • Interpersonal Communication • Prehospital Care Report • Special Documentation Issues

4. Communication Systems and Radio Communication

5. Communication Systems • EMS uses various communication systems: • Radios • One-way pagers • Cell phones • Traditional telephones (landlines) continued on next slide

6. Communication Systems • EMS radio systems consist of: • Base stations • Mobile radios • Portable radios • Repeaters • Cell phones • Telemetry

7. Repeaters Example of an EMS communication system using repeaters.

8. Radio Communication • Regulated by the Federal Communications Commission (FCC) • Assigns and licenses designated radio frequencies • Establishes rules regarding appropriate language • Monitors radio traffic

9. TABLE 15-1 Principles of Radio Communication

10. Radio Transmissions throughout the Call • Initial call often comes via telephone but may be radioed from another agency. • Without prompt and efficient dispatch and receipt of information, ambulances can be sent to the wrong location. • If two units transmit simultaneously, only one will be heard by listeners. continued on next slide

11. Radio Transmissions throughout the Call • Without prompt and efficient dispatch and receipt of information, ambulances can be sent to the wrong location. • Dispatch often confirms receipt of transmission by repeating part of it back. • Dispatch may end transmission with time for documentation. • According to 24-hour clock continued on next slide

12. Radio Transmissions throughout the Call • Carry portable radio whenever you leave unit. • Radios need proper care and maintenance.

13. Radio Medical Reports • Report must be given to destination hospital so it can prepare for arrival. • Usually done by radio • Structured to present only most important information • Speak clearly and slowly.

14. Radio Medical Reports Communication from the ambulance can be by radio or cell phone.

15. Medical Radio Reports • Unit identification and level of provider • Estimated time of arrival (ETA) • Patient's age and sex • Chief complaint • Brief, pertinent history of present illness/injury • Major past illnesses continued on next slide

16. Medical Radio Reports • Mental status • Baseline vital signs • Pertinent findings of physical exam • Emergency care given • Response to medical care • Contact Medical Direction if required or if you have a question continued on next slide

17. Medical Radio Reports • Communicating with medical direction • Give information clearly and accurately. • After receiving order or denial for medication or procedure, repeat back word for word. • If order unclear, ask physician to repeat. • If order seems inappropriate, question physician.

18. The Verbal Report

19. The Verbal Report • Given upon arrival at destination • Introduce patient by name. • Give complete and detailed report. continued on next slide

20. The Verbal Report • Elements of verbal report • Chief complaint • History that was not given previously • Assessment treatment given en route • Additional vital signs taken en route

21. Effective Communication Video Click on the screenshot to view a video on the subject of effective communication. Back to Directory

22. Interpersonal Communication

23. Team Communication • EMT must communicate with others involved in patient's care. • First responders • Advanced EMTs, paramedics • Home healthcare aides, family • Speak candidly and respectfully. • Collect information about patient.

24. FIGURE 15-3 You may need to communicate with Emergency Medical Responders or advanced EMS personnel at the scene.

25. Therapeutic Communication • Communication techniques learned by experience • May be more difficult with those in crisis • Everyone can improve communication skills. continued on next slide

26. Therapeutic Communication • Use eye contact. • Shows interest, comfort, and respect • Be aware of position and body language. • Face patient at eye level with arms down.

27. FIGURE 15-4 You may need to communicate with a home health aide or family member about the patient’s condition and present emergency.

28. Communication Techniques Communicating with patients and others who are in crisis requires skill and tact.

29. FIGURE 15-7 Be considerate of the elderly patient.

30. Therapeutic Communication • Use language the patient can understand. • Do not use medical terms. • Explain procedures. • Be honest. • Dishonesty ruins confidence and rapport. continued on next slide

31. Therapeutic Communication • Use patient's proper name. • Sign of respect, especially with older patients • Listen. • Important to establish trust

32. Communication Techniques Position yourself at or below the patient’s eye level to be less intimidating and to aid communication.

33. Therapeutic Communication • Special considerations • Always be compassionate and respectful if the patient: • Has a mental disability • Has visual or hearing impairments • Has any language barriers

34. Pediatric Note • Pediatric patients • Come down to their level. • Be truthful.

35. Communication Techniques Stay at a child’s eye level or lower.

36. Alternate Methods of Communication With Children Video Click here to view a video on the subject of communicating with children. Back to Directory

37. Prehospital Care Report

38. Prehospital Care Report • Written documentation of everything that happened during call • Several forms • Handwritten • Laptop • Tablet • Pen-based computers • Drop (transfer) report

39. FIGURE 15-10 (continued) Direct data devices as documentation tools: (A) a laptop pen-based computer and (B) a pen-based computer with PCR form on the screen. B

40. FIGURE 15-11 Example of a prehospital care report with fill-in boxes and a narrative space.

41. FIGURE 15-18 Example of a supplemental form.

42. FIGURE 15-19 Example of a special situation report.

43. FIGURE 15-17 During a multiple-casualty incident, triage tags are used to document information for each patient.

44. FIGURE 15-11 (continued) Example of a prehospital care report with fill-in boxes and a narrative space. B

45. FIGURE 15-12 An EMT completes her prehospital care report, using a computer in the receiving hospital ED.

46. Functions of the Prehospital Care Report • Patient Care Record • Documents findings and treatment • Conveys picture of scene • Entered into patient's permanent medical record continued on next slide

47. Functions of the Prehospital Care Report • Legal Document • Can be subpoenaed and used as evidence • May help patient win a case • May be used against you in case of negligence continued on next slide

48. Functions of the Prehospital Care Report • Administrative Purposes • Insurance information • Billing address continued on next slide

49. Functions of the Prehospital Care Report • Education and Research • Clinical research • Statistics • Continuing education • Tracking EMT's personal experience continued on next slide

50. Functions of the Prehospital Care Report • Quality Improvement • Routine call review • Ensures compliance to standards • Can reveal providers deserving special recognition • Can reveal opportunities for improvement