Communication and Documentation


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Communication and Documentation

  1. 1. Chapter Communication and Documentation Eleven
  2. 2. Chapter <ul><li>Delivery and format of patient care radio report </li></ul><ul><li>Principles of radio use </li></ul><ul><li>Purposes and principles of documentation of patient assessment and care </li></ul><ul><li>Documentation of special incidents </li></ul>Eleven CORE CONCEPTS
  4. 4. <ul><li>Be honest. </li></ul><ul><li>Use language the patient can </li></ul>understand. Interpersonal Communication Principles (Continued)
  5. 5. Maintain eye contact.
  6. 6. <ul><li>Be aware of your body </li></ul><ul><li>Speak slowly, clearly, and </li></ul>language. distinctly. Interpersonal Communication Principles (Continued)
  7. 7. Position yourself lower than patient.
  8. 8. <ul><li>Use the patient’s proper name. </li></ul>(Ask the patient what he/she wants to be called.) <ul><li>Act and speak in a calm, confident </li></ul>manner. Interpersonal Communication Principles (Continued)
  9. 9. <ul><li>Allow the patient enough </li></ul>time to answer each question. <ul><li>LISTEN! </li></ul><ul><li>Be aware of disabilities that may impair communications. </li></ul>Interpersonal Communication Principles (Continued)
  10. 10. <ul><li>Elderly patients may have visual </li></ul>or auditory deficits. <ul><li>Interpreters may be needed with </li></ul>non-English-speaking persons. Interpersonal Communication Principles
  11. 11. Base Station Components of a Communication System (Continued)
  12. 12. Mobile Two-Way Radios Portable Radios (Continued)
  13. 13. <ul><li>Repeaters </li></ul><ul><li>Digital radio equipment </li></ul><ul><li>Cellular telephones </li></ul><ul><li>Radio frequencies assigned </li></ul>Communication System Components and licensed by the Federal Communications Commission
  14. 14. <ul><li>Get consultation. </li></ul><ul><li>Obtain orders for </li></ul>medications/interventions. Communication with Medical Direction (Continued)
  15. 15. <ul><li>The physician determines </li></ul>the need for medications based on your report (be concise, accurate, and pertinent). (Continued) Communication with Medical Direction
  16. 16. After receiving an order: <ul><li>Repeat the order back </li></ul>word for word. <ul><li>Question orders that </li></ul>are unclear or appear to be inappropriate. Communication with Medical Direction
  17. 17. <ul><li>Call location and information </li></ul><ul><li>En route to scene/patient </li></ul><ul><li>Arrival at the scene/patient </li></ul><ul><li>En route to hospital </li></ul>(Continued) Communication with Dispatch
  18. 18. <ul><li>At hospital </li></ul><ul><li>Leaving hospital </li></ul><ul><li>Unusual situations </li></ul><ul><li>Request for assistance </li></ul>Communication with Dispatch
  19. 19. <ul><li>Listen before transmitting. </li></ul><ul><li>Press “Push to Talk” (PTT) button </li></ul>one second before speaking. <ul><li>Speak slowly and clearly. </li></ul>(Continued) Communication Principles
  20. 20. <ul><li>Avoid slang, codes, and profanity. </li></ul><ul><li>Do not give a patient's name over </li></ul>the air. <ul><li>Provide nonjudgmental, objective </li></ul>information. Communication Principles
  21. 21. <ul><li>Presents patient information </li></ul>to hospital. <ul><li>Allows hospital time to prepare. </li></ul><ul><li>High-quality report “paints a </li></ul>picture” of the patient with words. Radio Report
  22. 22. <ul><li>Unit and level of provider </li></ul><ul><li>Estimated time of arrival </li></ul><ul><li>Patient ’ s age and sex </li></ul><ul><li>Chief complaint </li></ul>(Continued) Radio Report: Content
  23. 23. <ul><li>Brief, pertinent history of </li></ul>present illness <ul><li>Major past illnesses </li></ul><ul><li>Mental status </li></ul><ul><li>Vital signs </li></ul>(Continued) Radio Report: Content
  24. 24. <ul><li>Pertinent findings of the </li></ul>physical exam <ul><li>Emergency medical care given </li></ul><ul><li>Response to emergency medical care </li></ul>Radio Report: Content
  25. 25. <ul><li>Introduce the patient by name. </li></ul><ul><li>Summarize information from </li></ul>the radio report. Verbal Communication at the Hospital radio report. <ul><li>Update what has changed since </li></ul>
  27. 27. <ul><li>Continuity of care </li></ul><ul><li>Legal document </li></ul><ul><li>Quality improvement </li></ul><ul><li>Education </li></ul><ul><li>Billing </li></ul><ul><li>Statistics and research </li></ul>Prehospital Care Report: Functions
  28. 28. <ul><li>Each piece of information is </li></ul>an element. <ul><li>Minimum elements have been </li></ul>established for a PCR (Continued) PCR Minimum Data Set
  29. 29. <ul><li>Standardized definitions </li></ul>for elements <ul><li>Aids in research </li></ul>(Continued) PCR Minimum Data Set
  30. 30. <ul><li>Chief complaint </li></ul><ul><li>Level of consciousness (AVPU) mental status </li></ul><ul><li>Systolic BP for patients more than 3 years old </li></ul><ul><li>Skin perfusion (capillary refill) for patients less than 6 years old </li></ul><ul><li>Skin color and temperature </li></ul><ul><li>Pulse rate </li></ul><ul><li>Respiratory rate and effort </li></ul>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. 31. <ul><li>Time of incident report </li></ul><ul><li>Time unit notified </li></ul><ul><li>Time of arrival at patient </li></ul><ul><li>Time unit left scene </li></ul><ul><li>Time of arrival at destination </li></ul><ul><li>Time of transfer of care </li></ul>PCR Minimum Data Set Administrative Information
  32. 32. PCR Run Data
  33. 33. PCR Patient Data
  34. 34. PCR Check Boxes
  35. 35. <ul><li>Avoid conclusions — be objective. </li></ul><ul><li>Include observations of the scene. </li></ul><ul><li>Include pertinent negatives. </li></ul><ul><li>Avoid slang and radio codes. </li></ul><ul><li>Use only standard abbreviations. </li></ul><ul><li>Use correct spelling. </li></ul>PCR Narrative
  36. 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. 37. <ul><li>Confidentiality </li></ul><ul><li>Distribution of copies </li></ul>PCR
  38. 38. <ul><li>May lead to revocation of </li></ul>certification/license. <ul><li>Leads to poor patient </li></ul>care. (Continued) Falsification of PCR
  39. 39. <ul><li>If an error in patient care </li></ul><ul><li>Note steps taken (if any) to correct the situation. </li></ul>occurs, document what did or didn ’ t happen. Falsification of PCR
  40. 40. Correction of Errors on PCR <ul><li>Draw a single horizontal </li></ul>. <ul><li>Write correct information </li></ul><ul><li>Do not obliterate the </li></ul>line through the error. beside it. error. (Continued)
  41. 41. <ul><li>Use different color of ink. </li></ul><ul><li>Correct error with single-line cross </li></ul><ul><li>Initial and date the correction. </li></ul><ul><li>If an error is discovered after </li></ul>form is submitted: out. Correction of Errors on PCR
  42. 42. <ul><li>Competent adult patients </li></ul>may legally refuse treatment. <ul><li>Patients must be informed </li></ul>of the consequences of refusing care. (Continued) Patient Refusal
  43. 43. <ul><li>Try to persuade the patient to </li></ul>accept care and transportation. <ul><li>Make sure the patient can </li></ul>make an informed, rational decision. (Continued) Patient Refusal
  44. 44. <ul><li>Document all assessment </li></ul><ul><li>Have patient sign refusal form. </li></ul><ul><li>Have witness sign refusal form. </li></ul>findings. (Continued) Patient Refusal
  45. 45. <ul><li>Document your attempts to </li></ul>convince patient to go to hospital. <ul><li>Document actions taken to </li></ul>protect patient after you leave. <ul><li>Contact medical direction if </li></ul>necessary. Patient Refusal
  46. 46. <ul><li>Insufficient time to fully </li></ul>MCI complete a PCR <ul><li>Use local forms or “tags” on </li></ul>the scene. <ul><li>Follow local MCI plan for </li></ul>documentation. Special Reporting Situations
  47. 47. <ul><li>Document unusual events. </li></ul><ul><li>Document injury or exposure. </li></ul><ul><li>Supplement or amplify </li></ul>primary reports. Special Situation Reports
  48. 48. 1. List the required elements of a radio report. 2. Describe ways to improve interpersonal communication. R EVIEW QUESTIONS