This document discusses communication and documentation in EMS, including history taking. It covers the importance of verbal and non-verbal communication skills for gathering information and coordinating care. Documentation in the form of a patient care report is described as the patient's permanent medical record that demonstrates appropriate care and aids future treatment. Taking a thorough history that includes signs and symptoms, allergies, medications, past medical history, last oral intake, and events leading to the injury or illness is also discussed.

1. Communication,
Documentation, History
Taking
Prepared by Odane P. Hamilton, EMT
Sept. 2015

2. Introduction (1 of 2)
 Communication is the transmission of information to
another person.
 Verbal
 Nonverbal (through body language)
 Verbal communication skills are important for the EMS
system.
 Enable you to gather critical information, coordinate
with other responders, and interact with other health
care professionals

3. Introduction (2 of 2)
 Documentation
 Patient’s permanent medical record
 Demonstrates appropriate care was delivered
 Helps others in patient’s future care
 Complete patient records
 Guarantee proper transfer of responsibility
 Comply with requirements of health departments and
law enforcement agencies
 Fulfill your organization’s administrative needs

4. Communication
 Uses various communication techniques and strategies:
 Both verbal and nonverbal
 Encourages patients to express how they feel
 Achieves a positive relationship with patient

5. Communication
 Communication model
 Sender takes a thought
 Encodes it into a message
 Sends the message to receiver
 Receiver decodes the message
 Sends feedback to the sender

6. Communication

7. Communication

8. Communication
Age, Culture, and Personal Experience
 Shape how a person communicates
 Body language and eye contact greatly affected by
culture
In some cultures, direct eye contact is impolite.
In other cultures, it is impolite to look away while
speaking.

9. Communication
Age, Culture and Personal Experience (cont’d)
 Tone, pace, and volume of language
 Reflect mood of person and perceived importance of
message
 Ethnocentrism: Considering your own cultural values more
important than those of others
 Cultural imposition: Forcing your values onto others

10. Communication
Non-verbal Communication
 Body language provides more information than words
alone.
 Facial expressions, body language, and eye contact are
physical cues.
 Help people understand messages being sent

11. Communication
Non-verbal Communication (cont’d)
 Physical factors
 Noise: Anything that dampens or obscures true meaning
of message
 Proxemics: Study of space and how distance between
people affects communication

12. Communication
Verbal Communication
 Asking questions is a fundamental aspect of prehospital
care.
 Open-ended questions require some level of detail.
Use whenever possible.
Example: “What seems to be bothering you?”

13. Communication
Verbal Communication (cont’d)
 Closed-ended questions can be answered in very short
responses.
Response is sometimes a single word.
Use if patients cannot provide long answers.
Example: “Are you having trouble breathing?”

14. Communication
Communication Tools
 There are many powerful
communication tools that
EMRs can use:
 Facilitation
 Silence
 Reflection
 Empathy
 Clarification
 Confrontation
 Interpretation
 Explanation
 Summary

15. Communication
Interviewing Techniques
 When interviewing a patient, consider using touch to show
caring and compassion.
 Use consciously and sparingly.
 Avoid touching the torso, chest, and face.

16. Communication
Interviewing Techniques (cont’d)
 Golden Rules to help calm and reassure patient:
 Make and keep eye contact at all times.
 Provide your name and use patient’s proper name.
 Tell patient the truth.

17. Communication
Interviewing Techniques (cont’d)
 Use language the patient can understand.
 Be careful what you say about patient to others.
 Be aware of your body language.
 Speak slowly, clearly, and distinctly.

18. Communication
Interviewing Techniques (cont’d)
 For the hearing-impaired patient, face patient so he or
she can read your lips.
 Allow the patient time to answer or respond.
 Act and speak in a calm, confident manner.

19. Communication
 Communicating with the Visually Impaired
 Ask the patient if he or she can see at all.
 Visually impaired patients are not necessarily
completely blind.
 Expect your patient to have normal intelligence.

20. Communication
 Communicating with the Visually Impaired (cont’d)
 Explain everything you are doing as you are doing it.
 Stay in physical contact with patient as you begin your
care.
 If patient can walk to ambulance, place his or her hand on
your arm.
 Transport mobility aids such as cane with patient to
hospital

21. Documentation
 Patient care report (PCR)
 Also known as prehospital care report
 Legal document
 Records all care from dispatch to hospital arrival

22. Documentation
 The PCR serves six main functions:
 Continuity of care
 Legal documentation
 Education
 Administrative information
 Essential research record
 Evaluation and continuous quality improvement

23. Documentation
 Information collected on the
PCR includes:
 Chief complaint
 Level of consciousness or
mental status
 Vital signs
 Initial assessment
 Patient demographics
 Time of events
 Assessment findings
 Emergency medical care provided
 Changes in patient after treatment
 Observations at the scene
 Final patient disposition
 Refusal of care
 Staff person who continued care

24. WHAT IS A PATIENT’S HISTORY?
WHY ARE PATIENT HISTORIES
IMPORTANT?

25. Patient History
 Accurate collection of information which
helps with assessment and management of
patient
 Should ideally come from patient directly
 May include, but not limited to, the
following:
Demographics (name, age, address,
contact number)
What happened to patient, when did
it occur, where affected, old vs new
injury
Mechanism of injury
(MOI)*
Past medical / surgical
history
Any medications
Chronic illnesses
Smoker / drinker
SAMPLE History*

26. IF IT SOUNDS
IMPORTANT, PUT
IT IN THE
HISTORY!

27. Mechanism of Injury
 The circumstance by which injury occurs
 Assesses severity of injury
 Affects the management of patient
 Examples:
Gun shot to the thigh from 50 yards
Head-on collision during rugby
Fall onto head from 3 feet
Twisting of ankle during 100m race
Cramp in the pool during exercise
Blunt trauma to the stomach by cricket bat
High speed motor vehicular accident

28. History Taking
 STEPS:
1. Scene size-up and BSI
2. Introduction to the patient and social history
3. Initial assessment (general inspection, assess ABCs,
alertness and mental status of patient  AVPU, presenting
complaint)

29. 4. Vital signs
5. SAMPLE History
6. Further considerations: GCS, OPQRST, DCAP-
BTLS
N.B. – When in doubt, ask a senior! Never
assume!

30. Approaching the Patient

31. Approaching the Patient - Considerations

32. Scene Size-Up and BSI
 Scene size-up
Steps taken by the responding crew when approaching the
scene of an emergency call
Method of observation
Scene safety
 BSI (Body Substance Isolation)
Any precaution taken by responder to protect his or herself
from coming into contact with patient’s bodily fluids or
other hazardous materials

33. Body Substance Isolation

34. Body Substance Isolation
Always clean hands after managing patients

35. Beginning and Approach
 Considerations
Approach patient from
line of sight
Speak clearly
Introduce yourself
Be polite
Be professional (patient;
NOT date)
Reassure patient
Do not lie about extent of
injury
Get patient’s consent to
treat! (touching a patient
without approval is
battery)
BE CALM!

36. Social History
 Considerations
Name
Age
Address
Contact number
Smoker: cigarettes, marijuana,
frequency of use
Drinking: socially, emotionally,
alone, quantity / quality /
frequency of drinking
Other illicit drug use
Any chronic illnesses,
personally or within family:
obesity, diabetes, high blood
pressure, sickle cell, bleeding
disorders, asthma, epilepsy,
fainting spells, migraines,
mental illness, high
cholesterol, valvular heart
disease, chronic infection

37. ABC…
 A – Airway
Is nose / oral cavity clear of obstruction
 B – Breathing
Respirations (breaths) per minute
One (1) respiration = 1 full inspiration (inhalation) + 1
full expiration (exhalation)
Breaths felt against side of face
Watch rise and fall of chest: shallow or deep, equal
or uneven on both sides

38. ABC… (cont’d)
 C – Circulation
Pulse rate (“heart rate”)
Perfusion to brain
Check at wrists (radial), neck (carotid), ankle
(posterior tibial), top of foot (dorsalis pedis)
Never use thumb for assessment! (thumb contains
own pulse)

39. AVPU
 Memory aid for classifying a patient’s level of
responsiveness or mental status
 A – alertness
Patient may be awake but confused (orientation to
person, place, time, event)
 V – verbal response
Response to normal speech/questions/commands vs
shouting to gain attention

40. AVPU (cont’d)
 P – painful response
Patient only responsive to painful stimulus (Eg.
Pinched toe, sternal rub, supraorbital pressure)
 U – unresponsive
Patient does not respond to any stimulus, whether it
be verbal or painful

41. Vital Signs
 Outward signs of what is going on inside the body
 Importance - gives responder an idea of state of
the patient, how best to manage and if to
transport to hospital

42. Vital Signs (cont’d)
 Includes:
Respiration rate (breathing rate; oxygen saturation –
“O2 sat.”)
Pulse rate (“heart rate”)
Skin colour and state of mucous membranes (pink
membrane under eyelids, gums)
Temperature (measured under armpit, not orally)
Blood pressure (manual > digital)

43. SAMPLE
 S – signs and symptoms
 A – allergies
 M – medications
 P – pertinent past medical history
 L – last oral intake
 E – events leading to the injury or illness

44. S. Signs and Symptoms
 Sign
Indication of a patient’s condition that is objective
I.e. – that which is observable and reported by the
medical authority
Can usually be tested by medial authority
E.g. – vital signs, vomitus, bleeding
 Symptom
Indication of a patient’s health that is subjective
I.e. – that which is felt or reported by the patient but
cannot be observed by medical authority
E.g. – chest pains, dizziness, nausea

45. S. Signs and Symptoms (cont’d)
 Considerations
How do you feel?
Do you feel better / worse?
Does anything help / aggravate the problem?

46. A. Allergies
 Medication
 Food
 Environment (grass, pollen, dust)
 Animals (fur, hair, bee/ wasp/ centipede/ ants/ spider/
scorpion stings and bites, faecal matter)
 Anaphylaxis – life threatening!
 Considerations
Is the patient wearing a medical ID badge?
What happens when you are exposed to stimulus?
Have you ever been hospitalized for this?

47. M. Medication
 Medication
any substance which can be used for the diagnosis,
treatment, cure or prevention of disease
 Drug
any substance that has a physiological effect when
ingested or otherwise introduced into the body
 For the consideration of EMS, the term ‘drug’ can be used
interchangeably with ‘medication’ when questioning the
patient as one needs to know if the patient is using any
recreational drugs (e.g. – marijuana)

48. M. Medication (cont’d)
 Considerations
Are you currently on any drugs: prescription, over-
the-counter, recreational?
What are you using the drugs for?
How often to you use these drugs and how much do
you use at a time?
Do you take any herbal supplements?
Are you allergic to any drugs?
Has your doctor recently switched your medication
or increased the dosage?

49. P. Pertinent Past History
 Helps assess if this is a reoccurring or recent complaint
 Considerations
Have you ever experienced this injury / illness before?
What did you do to make it better?
Did you seek medical consultation?
Have you been going to follow-ups for your complaint?
Have you had any recent hospitalizations / surgeries?

50. L. Last Oral Intake
 Especially important for patients who present with
fainting, dizziness or dehydration
 Also important to note for patients requiring surgery since
stomach contents can be vomited while under anaesthesia
 Low blood sugar (hypoglycaemia)
 Considerations
 When last did you eat or drink?
 What did you have to eat or drink?
 E.g - a litre of liquids could constitute either 1 litre of juice or
1 litre of beer; not the same thing!

51. E. Events leading up to injury/illness
 Considerations
When did the illness / injury occur?
What happened? How did it occur? What led up to it?
How long were you ill for?
Did you lose consciousness at point of impact /
injury?
Did you hit your head?

52. Further…
 In some cases, one may need to use more specific
methods of assessment for a patient
 Includes more advanced investigative techniques. If in
doubt, ALWAYS consult the senior responder! NEVER
ASSUME!
 GCS (Glasgow Coma Scale)
Forms a more in-depth assessment of APVU
More qualitative scale of alertness and
consciousness

53. Further… (cont’d)
 DCAP- BTLS
Mnemonic for assessment of specific soft tissue and
orthopaedic injury post trauma
Deformities, Contusions, Abrasions,
Puncture/Penetrations, Burns, Tenderness, Lacerations,
Swelling
 OPQRST
mnemonic used for gauging patient’s current complaint of
pain
Onset, Palliation/Provocation, Quality, Radiation,
Severity, Time

54. Summary
 What do you remember??

55. Review
1. When health care providers force their cultural values
onto their patients because they believe their values are
better, they are displaying __________.
A. ethnocentrism
B. proxemics
C. nonverbal communication
D. cultural imposition

56. Review (cont’d)
Answer: D
Rationale: Forcing your own cultural values onto others because you believe your
values are better is referred to as cultural imposition.

57. Review (cont’d)
2. Which of the following statements about the patient care
report (PCR) is true?
A. It is not a legal document in the eyes of the law.
B. It cannot be used for patient billing information.
C. It helps ensure efficient continuity of patient care.
D. It is for use only by the prehospital care provider.

58. Review (cont’d)
Answer: C
Rationale: The PCR is an important document for more than one reason. It helps
to ensure efficient continuity of patient care by providing the hospital with an
account of all prehospital assessments and treatment. It also serves as a legal
document that reflects the care provided by the EMT.

59. Review (cont’d)
3. After receiving an order from medical control over the
radio, the EMT should:
A. carry out the order immediately.
B. disregard the order if it is not understood.
C. obtain the necessary consent from the patient.
D. repeat the order to the physician word for word.

60. Review (cont’d)
Answer: D
Rationale: After receiving an order from medical control, the EMT should repeat
the order back to the physician word for word. This will ensure that he or she
heard the order correctly. After confirming the order, the EMT should obtain the
necessary consent from the patient.

61. Review (cont’d)
4. A 60-year-old man complains of chest pain. He is conscious and alert and
denies shortness of breath. Which of the following questions would be the
MOST appropriate to ask him?
A. “Were you exerting yourself when the chest pain began?”
B. “Does the pain in your chest move to either of your arms?”
C. “Does the pain in your chest feel like a stabbing sensation?”
D. “Do you have any heart problems or take any medications?”

62. Review (cont’d)
 Answer: D

63. Review (cont’d)
5. During your assessment of a 20-year-old man with a severe headache and
nausea, you ask him when his headache began, but he does not answer your
question immediately. You should:
A. repeat your question because he probably did not hear you.
B. allow him time to think about the question and respond to it.
C. ask him if he frequently experiences severe headaches and nausea.
D. tell him that you cannot help him unless he answers your questions.

64. Review (cont’d)
 Answer: B

65. Review (cont’d)
6. In what manner should you act and speak with a patient?
A. passive
B. authoritative
C. loud and official
D. calm and confident

66. Review (cont’d)
 Answer: D

67. Review (cont’d)
7. When communicating with a visually impaired patient, you should:
A. determine the degree of the patient’s impairment.
B. expect him or her to have difficulty understanding.
C. recall that most visually impaired patients are blind.
D. possess an in-depth knowledge of sign language.

68. Review (cont’d)
 Answer: A

69. Review (cont’d)
8. The patient care report (PCR) ensures:
A. research data.
B. legal protection.
C. quality assurance.
D. continuity of care.

70. Review (cont’d)
 Answer: D

71. Review (cont’d)
9. All information recorded on the PCR must be:
A. typewritten or printed.
B. considered confidential.
C. a matter of public record.
D. reflective of your opinion.

72. Review (cont’d)
 Answer: B

73. Reference
 Brady – Emergency Care; Daniel Limmer, Michael F. O’Keefe (11th Ed.)
 Jones and Bartlett – Emergency Care and Transportation of the Sick and
Injured – Andrew N. Pollak, et al (10th Ed.)