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.
Precepting is vital to promoting the competence, familiarity, confidence, and security of new nurses in a new environment. Historically, there have been few standardized or universally accepted guidelines for the curriculum that should be included in the preceptorship model.
We created this groundbreaking new course, The Preceptor Challenge, to provide the opportunity for practical application of theory-based precepting practice in a lifelike virtual hospital setting. The highly interactive course is available to nurses working in all patient care areas, and teaches how to apply best practices, and how to identify the rationale that makes these practices "best."
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.
There are several purposes of nursing documentation including providing a written record of patient care, guiding reimbursement, and serving as legal evidence. Documentation follows the nursing process and is organized by problems, interventions, and evaluations. Common documentation methods include narrative charting, problem-oriented medical records, focus charting, and computer-assisted charting. Accuracy, brevity, legibility, and completeness are important principles of nursing documentation.
Guidelines for recording and reportingNursing Path
The document discusses guidelines for proper documentation and reporting in healthcare. It emphasizes that documentation should be factual, accurate, complete, current, and organized. Factual information includes objective descriptions while subjective descriptions use clients' exact words. Accuracy involves precise measurements. Complete documentation contains all essential information. Current documentation is timely. Information should be organized logically. Proper documentation is necessary for efficient patient care and meets legal standards.
- The document discusses ISBAR, a communication tool adapted from SBAR to standardize verbal and written communication, especially telephone referrals.
- ISBAR stands for Identify, Situation, Background, Assessment, Request. It provides a framework to organize crucial patient information when communicating between clinicians.
- The document encourages readers to practice using ISBAR through examples and roleplays to improve referral quality and patient safety.
This document defines what an incident is and describes different types of incidents that can occur in a healthcare facility. It explains that an incident is an unplanned event that causes or has potential to cause injury, illness, damage, or other negative outcomes. The document then defines and provides examples of different incident types including near misses, no harm incidents, adverse events, and sentinel events in increasing order of severity. It concludes by covering the purpose, process, and timing of reporting incidents.
Importance of communication for hospital Part-1 or Healthcare communication. There are 6 stakeholders are there for a hospital. How it varied from one to another we have tried to figure out. The current slide is on nursing & their challenges for communication. Mostly 60% of the problems could be solve with the proper communication.
The document discusses patient safety definitions, goals, and best practices. It defines patient safety as working to avoid, manage, and treat unsafe acts in healthcare through the use of best practices leading to optimal patient outcomes. The goals are to provide a safe environment for all individuals by promoting a proactive, non-punitive culture that facilitates reporting of hazards, errors, near-misses, and other unsafe conditions. Key aspects that should be reported include unanticipated outcomes, infections, errors, near misses, and safety concerns. Effective communication, identifying patients correctly, improving medication safety, ensuring correct procedures, reducing infections, and mitigating fall risks are emphasized as important areas of focus.
Precepting is vital to promoting the competence, familiarity, confidence, and security of new nurses in a new environment. Historically, there have been few standardized or universally accepted guidelines for the curriculum that should be included in the preceptorship model.
We created this groundbreaking new course, The Preceptor Challenge, to provide the opportunity for practical application of theory-based precepting practice in a lifelike virtual hospital setting. The highly interactive course is available to nurses working in all patient care areas, and teaches how to apply best practices, and how to identify the rationale that makes these practices "best."
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.
There are several purposes of nursing documentation including providing a written record of patient care, guiding reimbursement, and serving as legal evidence. Documentation follows the nursing process and is organized by problems, interventions, and evaluations. Common documentation methods include narrative charting, problem-oriented medical records, focus charting, and computer-assisted charting. Accuracy, brevity, legibility, and completeness are important principles of nursing documentation.
Guidelines for recording and reportingNursing Path
The document discusses guidelines for proper documentation and reporting in healthcare. It emphasizes that documentation should be factual, accurate, complete, current, and organized. Factual information includes objective descriptions while subjective descriptions use clients' exact words. Accuracy involves precise measurements. Complete documentation contains all essential information. Current documentation is timely. Information should be organized logically. Proper documentation is necessary for efficient patient care and meets legal standards.
- The document discusses ISBAR, a communication tool adapted from SBAR to standardize verbal and written communication, especially telephone referrals.
- ISBAR stands for Identify, Situation, Background, Assessment, Request. It provides a framework to organize crucial patient information when communicating between clinicians.
- The document encourages readers to practice using ISBAR through examples and roleplays to improve referral quality and patient safety.
This document defines what an incident is and describes different types of incidents that can occur in a healthcare facility. It explains that an incident is an unplanned event that causes or has potential to cause injury, illness, damage, or other negative outcomes. The document then defines and provides examples of different incident types including near misses, no harm incidents, adverse events, and sentinel events in increasing order of severity. It concludes by covering the purpose, process, and timing of reporting incidents.
Importance of communication for hospital Part-1 or Healthcare communication. There are 6 stakeholders are there for a hospital. How it varied from one to another we have tried to figure out. The current slide is on nursing & their challenges for communication. Mostly 60% of the problems could be solve with the proper communication.
The document discusses patient safety definitions, goals, and best practices. It defines patient safety as working to avoid, manage, and treat unsafe acts in healthcare through the use of best practices leading to optimal patient outcomes. The goals are to provide a safe environment for all individuals by promoting a proactive, non-punitive culture that facilitates reporting of hazards, errors, near-misses, and other unsafe conditions. Key aspects that should be reported include unanticipated outcomes, infections, errors, near misses, and safety concerns. Effective communication, identifying patients correctly, improving medication safety, ensuring correct procedures, reducing infections, and mitigating fall risks are emphasized as important areas of focus.
Nurses must provide effective reporting both orally and in writing to ensure continuity of patient care. Common types of reports include change-of-shift reports to pass on important patient information when nurses change shifts, transfer reports which provide details on a patient's condition and treatment when moved between units, incident reports for documenting any unexpected medical events, and telephone reports to communicate time-sensitive patient information. Effective reporting involves concisely relaying objective and relevant details about a patient's status, treatment, and care needs to keep all healthcare providers well-informed.
Records created by healthcare workers are considered health records under UK law. Health records must be factual, consistent, accurate, dated, timed, signed, and avoid jargon. Poor record keeping can lead to issues like mistakes in care, complaints, disciplinary action, and even criminal proceedings. The main barrier to good record keeping is a lack of time. Records made by non-registered staff must be regularly countersigned by their supervisor.
Professionalism is the buzzword and used in all discussions of Medical Ethics and Health Professional Ethics.Over the last decade, health professional associations are embracing Professionalism to oppose financial motives of the for-profit corporate players from interfering with the fiduciary relationship between Provider and the Client.
Humorous cartoons have been added to provide non-offensive mild punches and aid critical self-reflection..
5th ed. NABH Accreditation Standards for Hospitals April 2020Dr Jitu Lal Meena
The document discusses quality improvement and creating a quality culture in India's healthcare system. It outlines the National Accreditation Board for Hospitals and Healthcare Providers (NABH) standards for healthcare organizations, which provide a framework for quality assurance and improvement. The standards focus on patient safety, quality of care, and building a culture of quality at all levels of an organization. It also provides details on some specific NABH standards related to access, assessment, continuity of care and laboratory services.
The document discusses communication strategies for difficult patient interactions. It provides a framework called NURS to improve communication by naming the patient's emotions, understanding and validating them, respecting their experience, and supporting partnership. Specific types of difficult patients are described such as angry, non-compliant, seductive, and manipulative patients. Strategies are outlined for each type, emphasizing active listening, validating concerns, and setting clear boundaries. The goal is to de-escalate conflicts and establish trust and shared understanding to improve the patient-provider relationship.
This document discusses various aspects of patient safety, including definitions, challenges, common errors, and strategies to improve safety. It defines patient safety as efforts to reduce unsafe acts in healthcare and describes how both active errors and latent system failures can lead to accidents. The document outlines factors that contribute to errors, such as complexity, limited knowledge, and human factors. It also discusses approaches to improving safety through a culture of safety, disclosure of errors, human factors engineering, and use of checklists and protocols.
This document discusses effective communication in healthcare. It identifies three components of communication: the sender, receiver, and message. In a doctor-patient interaction, the doctor is both the sender and receiver of information, so ensuring a shared understanding is important. Some keys to effective communication include: establishing rapport, active listening, body language, empathy, avoiding medical jargon, and addressing questions. Proper communication is also important for patient safety, such as during handovers which can utilize the ISBAR method. Special situations like breaking bad news require protocols to ensure compassionate and clear information sharing. Barriers to communication like language differences and disabilities also must be addressed.
The document outlines the International Patient Safety Goals (IPSG) which are aimed at reducing common causes of medical errors and improving patient safety. It discusses the goals of correctly identifying patients, improving communication effectiveness, improving safety of high-alert medications, ensuring correct surgery procedures, reducing healthcare-associated infections, and reducing risks of patient harm from falls. For each goal, it provides more details on the specific processes and standards involved in achieving that goal.
International Patient Safety Goals (IPSG) help accredited organizations address specific areas of concern in some of the most problematic areas of patient safety.
International-Patient-Safety-GoalsGoal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
Nursing documentation is important for several reasons:
1) It helps communicate between the healthcare team and prevents fragmentation, repetition, and delays in patient care.
2) Nursing documentation is used to establish nursing care plans and for auditing, research, education, and reimbursement purposes.
3) Documentation provides a comprehensive view of the patient's condition and treatment and can be used as legal evidence in court cases.
This document outlines a preceptorship program for new nurses. It defines preceptorship as a teaching method using a preceptor to mentor a preceptee (new nurse) through role modeling, feedback, and evaluation. The goals of the program are to support new nurses' transition to practice and produce competent nurses through structured support. The roles and expectations of preceptors and preceptees are described. Preceptors must be experienced nurses trained to support preceptees' learning and socialization. The preceptee program involves orientation, shadowing, skills practice, and regular feedback meetings over 12 months to integrate new nurses safely. Potential difficulties implementing the program include time demands and balancing support and evaluation roles.
The patient care team model became common following World War II and was influenced by wartime experiences. It aimed to create a team of care providers led by a professional nurse with an emphasis on effective communication and delegation. Today, patient care teams can include an RN and paramedic working cohesively together under the RN's leadership to provide excellent patient care through ongoing communication and utilizing each member's skills.
The Pressure Ulcer Scale for Healing (PUSH) tool is a validated tool used to measure pressure wound status over time. It measures wound size, exudate amount, and tissue type - the parameters most indicative of healing. Wound size is calculated by multiplying wound length by width. Exudate amount is estimated as none, light, moderate, or heavy after dressing removal. Tissue type scores the wound bed based on the presence of necrotic tissue, slough, granulation tissue, or reepithelialization. The PUSH tool provides an objective measure of a wound's status and progress.
Communication is the exchange of thoughts, feelings, and information between individuals through various verbal and nonverbal means. Effective communication is important for client safety, collaboration with diverse healthcare teams, and the current healthcare environment. The communication process involves a sender transmitting a message to a receiver through a channel. Factors like age, culture, emotions, and surroundings can influence communication. Therapeutic communication between nurses and clients is goal-oriented and aims to provide information, build trust, and show caring through techniques like active listening, empathy, and open-ended questions. Both nurses and clients are affected in their communication by factors like past experiences, health status, family situations, and workloads.
This document discusses various methods of documenting client records in healthcare settings. It provides details on:
1) Source-oriented records where each department documents in their own section, and problem-oriented medical records (POMR) where data is arranged by client problems.
2) The four components of a POMR - database, problem list, plan of care, and progress notes which can follow a SOAP or SOAPIER format.
3) Other charting methods like PIE (problem, intervention, evaluation) and guidelines for accurate documentation like documenting date/time, signature, legibility, and using approved abbreviations.
Nursing has evolved from an occupation to a profession through developing specialized knowledge and skills. It involves both the science of caring for individuals and an art of applying knowledge compassionately. As a profession, nursing meets criteria such as requiring advanced education and training, demonstrating high-level responsibilities, and being guided by a code of ethics. Nurses work in a broad scope of settings and play an important role in promoting health, preventing illness, and caring for those who are sick, disabled, or dying.
The document discusses documentation and reporting in healthcare. It defines documentation as a permanent record of client information and care. Documentation serves several purposes such as communication between providers, legal documentation, research, and education. The document outlines various methods of documentation including narrative charting, problem-oriented charting, and computerized documentation. It also discusses different types of records like the kardex, flow sheets, and discharge summary used for recording client data. Verbal reporting is also an important communication technique in healthcare.
The document outlines the legal rights and responsibilities of patients. It discusses the origins of patient rights in medical codes of ethics. Key patient rights include the right to considerate care, information about diagnosis/treatment, privacy/confidentiality, and refusing to participate in experiments. The document also discusses avenues for filing complaints, such as medical councils, consumer courts, civil courts, and criminal courts. Finally, it lists patient responsibilities like following treatment plans and making prompt payments.
The document discusses normal and altered urinary and bowel elimination, including the anatomy and physiology related to waste excretion, common problems that can disrupt normal elimination, and nursing responsibilities in assessing and promoting normal elimination or treating disrupted patterns. Nursing goals are maintaining or restoring normal elimination, preventing risks like skin breakdown, and managing conditions like incontinence, constipation, or the use of ostomies through various interventions.
Tubing misconnections in critical set up is often a grave error which needs to be addressed well with policies and standard operating procedures. A good understanding of the problem by the team will go a long way in preventing this mishap to ever happen in your team.
The 1950s in London saw a period of affluence and freedom following World War 2. Restrictions ended and prosperity increased as the reconstruction effort continued. American influences like music and fashion emerged, bringing new styles. Young Londoners grew more assertive, looking to the US as a model. Throughout the decade, London fashion evolved from austerity to include "ready-to-wear" clothing, new fabrics, and trends like the Teddy Boy look for men and Mary Quant's designs for women.
This document discusses guidelines for EMS documentation. It covers the minimum data set that should be collected, functions and formats of the prehospital care report, documenting patient care errors and refusals, and handling special situations like mass casualty incidents. Continuous quality improvement relies on thorough documentation to analyze and improve the EMS system.
Nurses must provide effective reporting both orally and in writing to ensure continuity of patient care. Common types of reports include change-of-shift reports to pass on important patient information when nurses change shifts, transfer reports which provide details on a patient's condition and treatment when moved between units, incident reports for documenting any unexpected medical events, and telephone reports to communicate time-sensitive patient information. Effective reporting involves concisely relaying objective and relevant details about a patient's status, treatment, and care needs to keep all healthcare providers well-informed.
Records created by healthcare workers are considered health records under UK law. Health records must be factual, consistent, accurate, dated, timed, signed, and avoid jargon. Poor record keeping can lead to issues like mistakes in care, complaints, disciplinary action, and even criminal proceedings. The main barrier to good record keeping is a lack of time. Records made by non-registered staff must be regularly countersigned by their supervisor.
Professionalism is the buzzword and used in all discussions of Medical Ethics and Health Professional Ethics.Over the last decade, health professional associations are embracing Professionalism to oppose financial motives of the for-profit corporate players from interfering with the fiduciary relationship between Provider and the Client.
Humorous cartoons have been added to provide non-offensive mild punches and aid critical self-reflection..
5th ed. NABH Accreditation Standards for Hospitals April 2020Dr Jitu Lal Meena
The document discusses quality improvement and creating a quality culture in India's healthcare system. It outlines the National Accreditation Board for Hospitals and Healthcare Providers (NABH) standards for healthcare organizations, which provide a framework for quality assurance and improvement. The standards focus on patient safety, quality of care, and building a culture of quality at all levels of an organization. It also provides details on some specific NABH standards related to access, assessment, continuity of care and laboratory services.
The document discusses communication strategies for difficult patient interactions. It provides a framework called NURS to improve communication by naming the patient's emotions, understanding and validating them, respecting their experience, and supporting partnership. Specific types of difficult patients are described such as angry, non-compliant, seductive, and manipulative patients. Strategies are outlined for each type, emphasizing active listening, validating concerns, and setting clear boundaries. The goal is to de-escalate conflicts and establish trust and shared understanding to improve the patient-provider relationship.
This document discusses various aspects of patient safety, including definitions, challenges, common errors, and strategies to improve safety. It defines patient safety as efforts to reduce unsafe acts in healthcare and describes how both active errors and latent system failures can lead to accidents. The document outlines factors that contribute to errors, such as complexity, limited knowledge, and human factors. It also discusses approaches to improving safety through a culture of safety, disclosure of errors, human factors engineering, and use of checklists and protocols.
This document discusses effective communication in healthcare. It identifies three components of communication: the sender, receiver, and message. In a doctor-patient interaction, the doctor is both the sender and receiver of information, so ensuring a shared understanding is important. Some keys to effective communication include: establishing rapport, active listening, body language, empathy, avoiding medical jargon, and addressing questions. Proper communication is also important for patient safety, such as during handovers which can utilize the ISBAR method. Special situations like breaking bad news require protocols to ensure compassionate and clear information sharing. Barriers to communication like language differences and disabilities also must be addressed.
The document outlines the International Patient Safety Goals (IPSG) which are aimed at reducing common causes of medical errors and improving patient safety. It discusses the goals of correctly identifying patients, improving communication effectiveness, improving safety of high-alert medications, ensuring correct surgery procedures, reducing healthcare-associated infections, and reducing risks of patient harm from falls. For each goal, it provides more details on the specific processes and standards involved in achieving that goal.
International Patient Safety Goals (IPSG) help accredited organizations address specific areas of concern in some of the most problematic areas of patient safety.
International-Patient-Safety-GoalsGoal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
Nursing documentation is important for several reasons:
1) It helps communicate between the healthcare team and prevents fragmentation, repetition, and delays in patient care.
2) Nursing documentation is used to establish nursing care plans and for auditing, research, education, and reimbursement purposes.
3) Documentation provides a comprehensive view of the patient's condition and treatment and can be used as legal evidence in court cases.
This document outlines a preceptorship program for new nurses. It defines preceptorship as a teaching method using a preceptor to mentor a preceptee (new nurse) through role modeling, feedback, and evaluation. The goals of the program are to support new nurses' transition to practice and produce competent nurses through structured support. The roles and expectations of preceptors and preceptees are described. Preceptors must be experienced nurses trained to support preceptees' learning and socialization. The preceptee program involves orientation, shadowing, skills practice, and regular feedback meetings over 12 months to integrate new nurses safely. Potential difficulties implementing the program include time demands and balancing support and evaluation roles.
The patient care team model became common following World War II and was influenced by wartime experiences. It aimed to create a team of care providers led by a professional nurse with an emphasis on effective communication and delegation. Today, patient care teams can include an RN and paramedic working cohesively together under the RN's leadership to provide excellent patient care through ongoing communication and utilizing each member's skills.
The Pressure Ulcer Scale for Healing (PUSH) tool is a validated tool used to measure pressure wound status over time. It measures wound size, exudate amount, and tissue type - the parameters most indicative of healing. Wound size is calculated by multiplying wound length by width. Exudate amount is estimated as none, light, moderate, or heavy after dressing removal. Tissue type scores the wound bed based on the presence of necrotic tissue, slough, granulation tissue, or reepithelialization. The PUSH tool provides an objective measure of a wound's status and progress.
Communication is the exchange of thoughts, feelings, and information between individuals through various verbal and nonverbal means. Effective communication is important for client safety, collaboration with diverse healthcare teams, and the current healthcare environment. The communication process involves a sender transmitting a message to a receiver through a channel. Factors like age, culture, emotions, and surroundings can influence communication. Therapeutic communication between nurses and clients is goal-oriented and aims to provide information, build trust, and show caring through techniques like active listening, empathy, and open-ended questions. Both nurses and clients are affected in their communication by factors like past experiences, health status, family situations, and workloads.
This document discusses various methods of documenting client records in healthcare settings. It provides details on:
1) Source-oriented records where each department documents in their own section, and problem-oriented medical records (POMR) where data is arranged by client problems.
2) The four components of a POMR - database, problem list, plan of care, and progress notes which can follow a SOAP or SOAPIER format.
3) Other charting methods like PIE (problem, intervention, evaluation) and guidelines for accurate documentation like documenting date/time, signature, legibility, and using approved abbreviations.
Nursing has evolved from an occupation to a profession through developing specialized knowledge and skills. It involves both the science of caring for individuals and an art of applying knowledge compassionately. As a profession, nursing meets criteria such as requiring advanced education and training, demonstrating high-level responsibilities, and being guided by a code of ethics. Nurses work in a broad scope of settings and play an important role in promoting health, preventing illness, and caring for those who are sick, disabled, or dying.
The document discusses documentation and reporting in healthcare. It defines documentation as a permanent record of client information and care. Documentation serves several purposes such as communication between providers, legal documentation, research, and education. The document outlines various methods of documentation including narrative charting, problem-oriented charting, and computerized documentation. It also discusses different types of records like the kardex, flow sheets, and discharge summary used for recording client data. Verbal reporting is also an important communication technique in healthcare.
The document outlines the legal rights and responsibilities of patients. It discusses the origins of patient rights in medical codes of ethics. Key patient rights include the right to considerate care, information about diagnosis/treatment, privacy/confidentiality, and refusing to participate in experiments. The document also discusses avenues for filing complaints, such as medical councils, consumer courts, civil courts, and criminal courts. Finally, it lists patient responsibilities like following treatment plans and making prompt payments.
The document discusses normal and altered urinary and bowel elimination, including the anatomy and physiology related to waste excretion, common problems that can disrupt normal elimination, and nursing responsibilities in assessing and promoting normal elimination or treating disrupted patterns. Nursing goals are maintaining or restoring normal elimination, preventing risks like skin breakdown, and managing conditions like incontinence, constipation, or the use of ostomies through various interventions.
Tubing misconnections in critical set up is often a grave error which needs to be addressed well with policies and standard operating procedures. A good understanding of the problem by the team will go a long way in preventing this mishap to ever happen in your team.
The 1950s in London saw a period of affluence and freedom following World War 2. Restrictions ended and prosperity increased as the reconstruction effort continued. American influences like music and fashion emerged, bringing new styles. Young Londoners grew more assertive, looking to the US as a model. Throughout the decade, London fashion evolved from austerity to include "ready-to-wear" clothing, new fabrics, and trends like the Teddy Boy look for men and Mary Quant's designs for women.
This document discusses guidelines for EMS documentation. It covers the minimum data set that should be collected, functions and formats of the prehospital care report, documenting patient care errors and refusals, and handling special situations like mass casualty incidents. Continuous quality improvement relies on thorough documentation to analyze and improve the EMS system.
This document discusses various aspects of effective documentation and communication for capacity building projects involving youth volunteers. It provides guidance on the skills and qualities needed for those leading such efforts, including the ability to connect with and understand youth, accept them as they are, and serve as a role model. It also outlines different methods for documentation, such as interviews, observation, photography, and participatory video, discussing their pros and cons. Throughout, it emphasizes the importance of documentation for coordination, tracking progress, and providing a shared understanding for all stakeholders in a project.
This document discusses direction of arrival (DOA) estimation using a two-element antenna array. It describes simulating different radiation patterns from varying the phase between antennas. Randomly located nodes are generated and their received signal strength calculated using a two-ray model for different radiation patterns. The pattern with the highest RSS value for a node indicates the most likely region it is located in, allowing estimation of each node's DOA. While results show this method can determine DOA, more research is needed to narrow estimates.
This document discusses medical/legal and ethical issues that EMTs may encounter, including scope of practice, advance directives like DNR orders, patient consent and refusal, and assessment and care at crime scenes. It defines an EMT's scope of practice and responsibilities. It explains that advance directives require written physician orders and that patients have the right to refuse resuscitation efforts or treatment, which EMTs must document thoroughly. It also notes that crime scenes require protecting evidence while providing medical care and being observant without interfering.
1. This chapter discusses medications that EMT-Bs can assist patients with or carry on ambulances, including activated charcoal, oxygen, nitroglycerin, epinephrine, and aspirin. It also covers medication administration procedures.
2. EMT-Bs must ensure the right patient, right medication, right dose, right route, and right documentation when assisting with medications.
3. Common medication forms include tablets, liquids, gases, gels, suspensions, inhalers, and injectables.
This document discusses the importance of medical record keeping and provides guidance on the key components and structure of a medical record. It emphasizes that the primary purpose of medical records is to serve the physician's memory and communicate information to other providers to facilitate quality patient care. The document outlines the standard sections of a medical record including identification information, chief complaint, history of present illness, past medical history, review of systems, medications, allergies, physical examination, assessment, and plan. It provides details on what should be included in each section to fully document a patient's medical history and care.
The document discusses effective techniques for taking a patient's medical history. It recommends starting with standard questions about the chief complaint, including location, quality, duration, aggravating/relieving factors, and effect on function. The history aims to identify relevant organ systems, clarify pathological processes, and characterize the social context of the patient's illness. Key elements include patient identification, profile, and chief complaints. Effective techniques include adopting a conversational style, listening without interrupting, clarifying terms, summarizing, and utilizing open-ended questions initially.
Patient Assessment And Clinical Interviewingdunerafael
The document provides guidance on common mistakes healthcare practitioners make in patient communication and assessment. It discusses the importance of greeting patients, understanding their concerns, asking open-ended questions, being attentive to verbal and non-verbal cues, avoiding judgements, and understanding cultural beliefs. It also outlines key information to collect during a patient assessment, including medical history, medications, allergies and social factors, and provides examples of documentation through a SOAP note.
This online English course teaches nurses the language skills needed to communicate effectively in their work. The course covers essential interactions and situations, including caring for patients, clinical procedures, medication administration, and end-of-life care. It is designed for nurses with an elementary or pre-intermediate English level who work in English-speaking environments. Through a variety of materials and exercises, the course builds nurses' English vocabulary, grammar, and pronunciation over 10 units focusing on key nursing topics.
This document provides an overview of the history taking and physical examination process. It discusses the components of a comprehensive history, including the chief complaint, present illness, past medical history, family history, social history and review of systems. It also outlines the equipment, sequence and techniques involved in performing a thorough physical exam, including inspection, palpation, percussion and auscultation. The document emphasizes that most of the important information to make a diagnosis comes from the patient's history, not physical exam or tests.
The presentation describes in brief the patients need, expectations and how to develop the patient care and feedback system to obtain maximum patient satisfaction.
This document discusses key concepts for patient assessment and communication in medical imaging. It emphasizes the importance of critical thinking, problem solving, cultural awareness and establishing effective communication. The radiographer must collect subjective and objective data on the patient, analyze the data to develop a customized care plan, implement the plan and evaluate the results. Nonverbal communication, gender factors and other variables that could impact the patient experience are also addressed.
This document discusses key concepts for patient assessment and communication in medical imaging. It emphasizes the importance of critical thinking, problem solving, cultural awareness and establishing rapport when interacting with patients. Effective communication involves both verbal and nonverbal elements, with factors like gender, disabilities and grief needing consideration. The goals are to obtain necessary medical histories, explain procedures, ensure patient comfort and provide education to support patient rights and self determination.
This document discusses key concepts for patient assessment and communication in medical imaging. It emphasizes the importance of critical thinking, problem solving, cultural awareness and establishing rapport when interacting with patients. The radiographer must collect both subjective and objective data about the patient, analyze the information to develop an individualized care plan, implement the plan and evaluate the results. Nonverbal communication, gender factors and other variables that could impact the patient experience are also addressed.
This document discusses key concepts for patient assessment and communication in medical imaging. It emphasizes the importance of critical thinking, problem solving, cultural awareness and establishing rapport when interacting with patients. The radiographer must collect both subjective and objective data about the patient, analyze the information to develop an individualized care plan, implement the plan and evaluate the results. Non-verbal communication, gender factors and other variables that could impact the patient experience are also addressed.
Health assessment - physical assessmentjhonee balmeo
This document provides information about performing a health assessment. It discusses that a health assessment identifies a person's specific health needs and how those needs will be addressed. It involves taking a health history and performing a physical examination to evaluate the person's health status. Health assessments can be performed by both physicians and nurses, and the type of assessment varies depending on the healthcare professional's role and setting. The document then goes into detail about the different types of assessments, components of assessments, and techniques used during the physical examination portion of an assessment.
3 history taking & physical examinationawadfadlalla1
This document provides information on nursing history taking and physical examination. It discusses the importance of obtaining an accurate patient history, which is critical for diagnosis. The key components of history taking are identified as demographic data, chief complaint, history of present illness, past medical history, family history, drug history, review of systems, and physical examination. The principles and techniques of physical examination are outlined, including inspection, palpation, percussion, and auscultation. A head-to-toe assessment approach is recommended to perform a thorough physical exam.
Therapeutic communication techniques are essential for collecting patient information and building rapport. These include using open-ended questions to gather details, active listening skills like restatement and reflection, and observing nonverbal cues. The medical assistant prepares for and assists with the physical exam by setting up supplies, positioning the patient appropriately, and ensuring comfort. The exam follows a head-to-toe sequence and incorporates inspection, auscultation, and other objective assessment methods. Maintaining patient privacy, confidentiality, and centered care are important legal and ethical duties of medical assistants.
The document discusses the importance of effective communication in healthcare. It notes that communication is vital for understanding patients, assessing needs, and teamwork. However, barriers like lack of training and time can negatively impact communication. Poor communication has been a factor in many medical complaints and litigation. The document provides guidance on techniques for delivering bad news, addressing patient reactions, and improving communication skills through training. Effective communication can help patients better manage the consequences of bad news.
The document discusses the importance of taking a thorough medical history. It outlines that a history is the first step in diagnosis and is often the least expensive way to determine the correct diagnosis. It also emphasizes that history taking requires establishing rapport with the patient and developing one's own systematic technique through practice and experience. A table provides a suggested sequence for obtaining a patient's history.
The document provides information on how to take a patient's medical history. It discusses the components of a medical history including:
1. Chief complaint - the patient's reason for visiting stated in their own words.
2. History of present illness (HPI) - details of the current illness including duration, severity, treatments tried, and associated symptoms.
3. Past medical history (PHM) - includes past illnesses, surgeries, medications, allergies, hospitalizations, and health maintenance.
4. Family history - focuses on hereditary illnesses in first and second degree relatives.
The document emphasizes using open-ended questions and following up with questions about duration, severity and other details to fully understand
This document provides guidelines for effective communication in healthcare settings. It discusses best practices for breaking bad news, handling adverse events, dealing with aggressive patients/families, and medication reconciliation. Key recommendations include disclosing information honestly, ensuring privacy, maintaining eye contact, answering all questions, and documenting discussions. The primary consultant should communicate major issues while involving other stakeholders as needed.
The goal of patient interviews is to develop a therapeutic relations.docxrtodd194
The goal of patient interviews is to develop a therapeutic relationship and make a diagnosis. A therapeutic relationship comprises the healthcare provider and patient feeling comfortable with each other. The patient comes to the interview to seek relief from an illness, while the healthcare provider understands the patient's problems to provide a remedy. They trust that the care provider will listen to the issues and offer them comfort and confidence (Dang et al., 2017). Diagnosis involves an evaluation of the patient's signs and symptoms. The care practitioner obtains information on the patient's signs and symptoms by asking specific questions. At the end of the interview, the practitioner comes up with a differential diagnosis to determine appropriate treatment options.
The healthcare provider needs to follow specific interview guidelines. For instance, the interview setting ought to be comfortable, free from disturbances, and discreet. Besides, the questions should be open-ended, focused, and specific to allow patients to express themselves. Also, the care provider needs to ask the patient for clarification and make further explanations. Additionally, the healthcare practitioner ought to be emphatic and pay attention to the patient's emotional responses.
Healthcare providers are likely to make mistakes when providing care for students. I remember an incident where I used an improper technique to measure a patient's blood pressure. The patient was a teenager who had fainted at the school playground. I put the sphygmomanometer on the patient's arm without removing his sweater. Due to this mistake, the patient's blood pressure measurements increased by 40 points. The overall high blood pressure points seemed odd since there was no history of blood pressure or anxiety. While retracing my steps, I identified that the patient had his sweater on, which explained the elevated pressure. The incident made me learn that staying calm during emergencies is significant.
Medical history refers to a report that has the medical recollections and concerns of a patient. The critical components of a patient history are chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past, family, and social history (PFSH). Chief complaint or concern refers to the patient's primary reason for a visit, such as persistent headaches. HPI is the patient's comprehensive details of the chief complaint and the symptom progression (Mathioudakis et al.,2016). For instance, constant headaches for one week, causing dizziness. The ROS involves a list of questions that seek to obtain further information on the patient's additional symptoms or previous and current problems. Lastly, the PFSH comprises information on the patient's previous illnesses, medications, and incidence among family members.
Healthcare providers should be culturally competent when providing care. Doing so will prevent misunderstandings and barriers from caring. I have e.
This document outlines the topics and contents to be covered in a course on patient assessment and history taking for the respiratory system. The course will cover topics like introduction and history taking, cardiopulmonary symptoms, vital signs, respiratory examinations, neurological assessments, and more. It will teach principles of communication, techniques for interviewing patients, and the structure of a medical history, including collecting information on the chief complaint, present illness, past medical history, and social history. The goal is to train participants to properly assess patients and obtain an organized medical history focused on the respiratory system.
Similar to Communication, Documentation, History Taking (20)
A presentation on Social Media DOs and DON'Ts done for the Anglican Church in Jamaica and the Cayman Islands.
Presentation was conducted at Mandeville Hotel in Jamaica.
This certificate of participation recognizes Odane P. Hamilton for attending a 5-part webinar series on preparing for a successful career. The series covered important career skills like those sought by employers, networking and the hidden job market, starting a job search, resume writing, and interviewing. Experts from Cisco Systems led the sessions on different facets of career preparation.
The student successfully completed the CCNA Routing and Switching: Connecting Networks course administered by the instructor. Over the course, the student gained proficiency in understanding, configuring, and troubleshooting tunneling, NAT, network monitoring using syslog, SNMP and NetFlow. The student also learned about WAN technologies, VPNs, serial and broadband connections, and describing different network architectures.
Odane P. Hamilton has completed the Cisco CCNA Routing and Switching: Connecting Networks course through Cisco Networking Academy, earning a Certificate of Completion. The course provided hands-on training to prepare Hamilton for a career in technology by teaching skills like understanding different WAN technologies, configuring and troubleshooting VPNs and tunnels, and monitoring networks using tools like SNMP and NetFlow. The CEO of Cisco congratulated Hamilton and wished him continued success.
Asthma is a chronic inflammatory disease of the airways that causes wheezing, coughing, chest tightness and shortness of breath. Triggers include air pollution, animal fur, exercise and weather changes. Symptoms are coughing, wheezing, chest tightness and difficulty breathing. Medications include long-term controllers to manage symptoms, quick relievers for attacks, and allergy medications. Treatment involves calming the patient, assisting with inhalers or nebulizers, and monitoring for side effects like increased heart rate or nausea.
This certificate recognizes participation in a webinar series about the value of certifications. The series provided information on studying for exams, resources to help prepare, and discussions with alumni and managers who emphasized how certifications benefit employment.
Odane P. Hamilton has completed the Cisco CCNA Routing and Switching: Scaling Networks course and earned a Certificate of Completion. Through this hands-on course, Odane learned how to understand, configure, and troubleshoot technologies like VLANs, RSTP, PVST+, EtherChannel, HSRP, wireless routers and clients, and routing protocols including OSPF, EIGRP, and IPv4 and IPv6 networks. Technological literacy is important, and Cisco is proud to provide the knowledge and skills to build and maintain computer networks.
This certificate of completion recognizes that the student, Odane P. Hamilton from the Department of Computing at UWI Mona in Jamaica, successfully completed the Cisco Networking Academy CCNA Routing and Switching: Scaling Networks course administered by their instructor. Based on the instructor's evaluation, the student demonstrated proficiency in configuring and troubleshooting routers and switches using protocols like OSPF, EIGRP, VLANs, RSTP, PVST+, EtherChannel, HSRP, and managing wireless clients and routers.
CCNA Routing and Switching - Routing and Switching EssentialsOdane P. Hamilton
The student completed the Cisco Networking Academy course administered by the instructor. Through the course, the student gained proficiency in understanding and configuring access control lists, DHCP, DNS, NAT, basic switching concepts, enhanced switching technologies, dynamic and distance vector routing protocols, and VLANs for IPv4 and IPv6 networks. The student received a certificate of completion for the CCNA Routing and Switching: Routing and Switching Essentials course.
CCNA Routing and Switching - Introduction to NetworksOdane P. Hamilton
The student completed the Cisco Networking Academy course administered by the instructor. Through the course, the student learned to explain Ethernet concepts, build simple Ethernet networks using routers and switches, and use Cisco CLI commands to perform basic router and switch configurations. The student also gained an understanding of devices and services used in data networks, the role of protocol layers, and the importance of addressing and naming schemes in IPv4 and IPv6 environments.
Certificate of Completion - Be Your Own Boss - Module 7Odane P. Hamilton
Certificate of Completion was awarded to Odane P. Hamilton on Oct 11, 2015 for completing the Cisco Networking Academy® Be Your Own Boss: Module 7 course. The course demonstrated the ability to outline elements of a business relationship and explain elements of a business contract and customer service.
Certificate of Completion - Be Your Own Boss - Module 6Odane P. Hamilton
This certificate of completion recognizes Odane P. Hamilton for finishing the Cisco Networking Academy course "Be Your Own Boss: Module 6" on October 11, 2015. The course covered outlining ways to test business ideas through self-evaluation, teamwork, and market research, as well as describing pilot programs with small, achievable, measurable, and repeatable steps.
Certificate of Completion - Be Your Own Boss - Module 5Odane P. Hamilton
This certificate of completion recognizes that Odane P. Hamilton completed the Cisco Networking Academy® Be Your Own Boss: Module 5 course on October 11, 2015. The course demonstrated his ability to summarize the questions needed to create a business plan and design a business plan.
Certificate of Completion - Be Your Own Boss_Module 3Odane P. Hamilton
Odane P. Hamilton completed the Cisco Networking Academy® Be Your Own Boss: Module 3 course on March 30, 2015 and demonstrated the ability to explain methods of thinking valuable to a technopreneur and evaluate flaws in business ideas. A Certificate of Completion was presented to Odane P. Hamilton for finishing the course.
Certificate of Completion - Be Your Own Boss_Module 1Odane P. Hamilton
This certificate of completion recognizes Odane P. Hamilton for finishing the Cisco Networking Academy® Be Your Own Boss: Module 1 course on April 11, 2015. The course demonstrated an ability to explain the process of becoming a Technopreneur and identify the elements of Technopreneurship.
This document provides an overview of chest, abdominal, and genitourinary injuries. It discusses the anatomy and physiology of the chest and abdominal cavities. Key points include recognition of blunt versus penetrating chest and abdominal trauma. Chest injuries can involve the lungs and heart. Signs may include difficulty breathing, coughing up blood, and unequal chest rise. Abdominal injuries can damage solid organs like the liver or hollow organs like the intestines. Signs may include pain, guarding, bruising, or distention. Proper assessment and treatment focus on the ABCs, with priorities being control of bleeding and treatment for shock.
Vital signs provide important information about a patient's physiological status. They include level of consciousness, pupils, breathing, pulse, skin, blood pressure, and temperature. Assessing vital signs involves evaluating factors like respiratory rate and depth, pulse rate and quality, skin color and temperature, and blood pressure. Together, vital signs give medical responders insight into a patient's condition to determine the best treatment and need for transport.
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
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*
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!
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
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
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?”
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.
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.
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.
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.)