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Communication and Documentation

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  • 1. Chapter Communication and Documentation Eleven
  • 2. Chapter
    • Delivery and format of patient care radio report
    • Principles of radio use
    • Purposes and principles of documentation of patient assessment and care
    • Documentation of special incidents
    Eleven CORE CONCEPTS
  • 3. C OMMUNICATIONS
  • 4.
    • Be honest.
    • Use language the patient can
    understand. Interpersonal Communication Principles (Continued)
  • 5. Maintain eye contact.
  • 6.
    • Be aware of your body
    • Speak slowly, clearly, and
    language. distinctly. Interpersonal Communication Principles (Continued)
  • 7. Position yourself lower than patient.
  • 8.
    • Use the patient’s proper name.
    (Ask the patient what he/she wants to be called.)
    • Act and speak in a calm, confident
    manner. Interpersonal Communication Principles (Continued)
  • 9.
    • Allow the patient enough
    time to answer each question.
    • LISTEN!
    • Be aware of disabilities that may impair communications.
    Interpersonal Communication Principles (Continued)
  • 10.
    • Elderly patients may have visual
    or auditory deficits.
    • Interpreters may be needed with
    non-English-speaking persons. Interpersonal Communication Principles
  • 11. Base Station Components of a Communication System (Continued)
  • 12. Mobile Two-Way Radios Portable Radios (Continued)
  • 13.
    • Repeaters
    • Digital radio equipment
    • Cellular telephones
    • Radio frequencies assigned
    Communication System Components and licensed by the Federal Communications Commission
  • 14.
    • Get consultation.
    • Obtain orders for
    medications/interventions. Communication with Medical Direction (Continued)
  • 15.
    • The physician determines
    the need for medications based on your report (be concise, accurate, and pertinent). (Continued) Communication with Medical Direction
  • 16. After receiving an order:
    • Repeat the order back
    word for word.
    • Question orders that
    are unclear or appear to be inappropriate. Communication with Medical Direction
  • 17.
    • Call location and information
    • En route to scene/patient
    • Arrival at the scene/patient
    • En route to hospital
    (Continued) Communication with Dispatch
  • 18.
    • At hospital
    • Leaving hospital
    • Unusual situations
    • Request for assistance
    Communication with Dispatch
  • 19.
    • Listen before transmitting.
    • Press “Push to Talk” (PTT) button
    one second before speaking.
    • Speak slowly and clearly.
    (Continued) Communication Principles
  • 20.
    • Avoid slang, codes, and profanity.
    • Do not give a patient's name over
    the air.
    • Provide nonjudgmental, objective
    information. Communication Principles
  • 21.
    • Presents patient information
    to hospital.
    • Allows hospital time to prepare.
    • High-quality report “paints a
    picture” of the patient with words. Radio Report
  • 22.
    • Unit and level of provider
    • Estimated time of arrival
    • Patient ’ s age and sex
    • Chief complaint
    (Continued) Radio Report: Content
  • 23.
    • Brief, pertinent history of
    present illness
    • Major past illnesses
    • Mental status
    • Vital signs
    (Continued) Radio Report: Content
  • 24.
    • Pertinent findings of the
    physical exam
    • Emergency medical care given
    • Response to emergency medical care
    Radio Report: Content
  • 25.
    • Introduce the patient by name.
    • Summarize information from
    the radio report. Verbal Communication at the Hospital radio report.
    • Update what has changed since
  • 26. D OCUMENTATION
  • 27.
    • Continuity of care
    • Legal document
    • Quality improvement
    • Education
    • Billing
    • Statistics and research
    Prehospital Care Report: Functions
  • 28.
    • Each piece of information is
    an element.
    • Minimum elements have been
    established for a PCR (Continued) PCR Minimum Data Set
  • 29.
    • Standardized definitions
    for elements
    • Aids in research
    (Continued) PCR Minimum Data Set
  • 30.
    • Chief complaint
    • Level of consciousness (AVPU) mental status
    • Systolic BP for patients more than 3 years old
    • Skin perfusion (capillary refill) for patients less than 6 years old
    • Skin color and temperature
    • Pulse rate
    • Respiratory rate and effort
    Gathered at the time of the EMT-B’s initial contact with patient on arrival at scene, following all interventions, and on arrival at facility PCR Minimum Data Set Patient Information
  • 31.
    • Time of incident report
    • Time unit notified
    • Time of arrival at patient
    • Time unit left scene
    • Time of arrival at destination
    • Time of transfer of care
    PCR Minimum Data Set Administrative Information
  • 32. PCR Run Data
  • 33. PCR Patient Data
  • 34. PCR Check Boxes
  • 35.
    • Avoid conclusions — be objective.
    • Include observations of the scene.
    • Include pertinent negatives.
    • Avoid slang and radio codes.
    • Use only standard abbreviations.
    • Use correct spelling.
    PCR Narrative
  • 36. Writing a good PCR is a skill that most people must practice to be good at. Instead of overwhelming new EMT-Bs with this task, introduce them to it gradually. On relatively simple calls at first, have new EMT-Bs write the form as you dictate it. As understanding grows, have them write out the narrative section on a blank piece of paper, not the PCR. This allows you to suggest corrections and improvements without worrying about neatness. As EMT-Bs gain more confidence, they can write on the PCR directly for more difficult calls. P RECEPTOR P EARL
  • 37.
    • Confidentiality
    • Distribution of copies
    PCR
  • 38.
    • May lead to revocation of
    certification/license.
    • Leads to poor patient
    care. (Continued) Falsification of PCR
  • 39.
    • If an error in patient care
    • Note steps taken (if any) to correct the situation.
    occurs, document what did or didn ’ t happen. Falsification of PCR
  • 40. Correction of Errors on PCR
    • Draw a single horizontal
    .
    • Write correct information
    • Do not obliterate the
    line through the error. beside it. error. (Continued)
  • 41.
    • Use different color of ink.
    • Correct error with single-line cross
    • Initial and date the correction.
    • If an error is discovered after
    form is submitted: out. Correction of Errors on PCR
  • 42.
    • Competent adult patients
    may legally refuse treatment.
    • Patients must be informed
    of the consequences of refusing care. (Continued) Patient Refusal
  • 43.
    • Try to persuade the patient to
    accept care and transportation.
    • Make sure the patient can
    make an informed, rational decision. (Continued) Patient Refusal
  • 44.
    • Document all assessment
    • Have patient sign refusal form.
    • Have witness sign refusal form.
    findings. (Continued) Patient Refusal
  • 45.
    • Document your attempts to
    convince patient to go to hospital.
    • Document actions taken to
    protect patient after you leave.
    • Contact medical direction if
    necessary. Patient Refusal
  • 46.
    • Insufficient time to fully
    MCI complete a PCR
    • Use local forms or “tags” on
    the scene.
    • Follow local MCI plan for
    documentation. Special Reporting Situations
  • 47.
    • Document unusual events.
    • Document injury or exposure.
    • Supplement or amplify
    primary reports. Special Situation Reports
  • 48. 1. List the required elements of a radio report. 2. Describe ways to improve interpersonal communication. R EVIEW QUESTIONS