The document discusses principles of communication and documentation for patient care. It outlines the required elements of a radio report which include unit and provider level, estimated time of arrival, patient age and sex, chief complaint, history, vital signs, physical exam findings, treatment, and response to care. It also describes ways to improve interpersonal communication such as using clear language, maintaining eye contact, speaking slowly, and listening to the patient. Proper documentation is also covered, including the minimum data set required for a patient care report and correcting errors on documentation.

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