ChapterChapter

CommunicationCommunication

andand

DocumentationDocumentation

ElevenEleven

ChapterChapter

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

ElevenEleven CORE CONCEPTSCORE CONCEPTS

CCOMMUNICATIONSOMMUNICATIONS

Be honest.Be honest.

Use language the patient can Use language the patient can

understand.understand.

InterpersonalInterpersonalCommunication PrinciplesCommunication Principles

(Continued)(Continued)

Maintain eye contact.Maintain eye contact.

Be aware of your body Be aware of your body

Speak slowly, clearly, andSpeak slowly, clearly, and

language.language.

distinctly.distinctly.

InterpersonalInterpersonalCommunication PrinciplesCommunication Principles

(Continued)(Continued)

Position yourself lower than patient.Position yourself lower than patient.

Use the patient’s proper name. Use the patient’s proper name. (Ask the patient what he/she wants to be called.)(Ask the patient what he/she wants to be called.)

Act and speak in a calm, confidentAct and speak in a calm, confidentmanner.manner.

InterpersonalInterpersonalCommunication PrinciplesCommunication Principles

(Continued)(Continued)

Allow the patient enoughAllow the patient enoughtime to answer each question.time to answer each question.

LISTEN!LISTEN! Be aware of disabilities that mayBe aware of disabilities that may impair communications. impair communications.

InterpersonalInterpersonalCommunication PrinciplesCommunication Principles

(Continued)(Continued)

Elderly patients may have visualElderly patients may have visualor auditory deficits.or auditory deficits.

Interpreters may be needed withInterpreters may be needed withnon-English-speaking persons.non-English-speaking persons.

InterpersonalInterpersonalCommunication PrinciplesCommunication Principles

Base StationBase Station

Components of aComponents of aCommunication SystemCommunication System

(Continued)(Continued)

Mobile Two-Way RadiosMobile Two-Way Radios

Portable RadiosPortable Radios

(Continued)(Continued)

RepeatersRepeaters Digital radio equipmentDigital radio equipment Cellular telephonesCellular telephones Radio frequencies assignedRadio frequencies assigned

Communication SystemCommunication SystemComponentsComponents

and licensed by the Federaland licensed by the FederalCommunications CommissionCommunications Commission

Get consultation.Get consultation. Obtain orders forObtain orders for

medications/interventions.medications/interventions.

Communication Communication with Medical Directionwith Medical Direction

(Continued)(Continued)

The physician determinesThe physician determinesthe need for medications the need for medications based on your report (be based on your report (be concise, accurate, and concise, accurate, and pertinent).pertinent).

(Continued)(Continued)

Communication Communication with Medical Directionwith Medical Direction

After After receivingreceivingan order:an order:

Repeat the order back word for word.

Question orders that are unclear or appear to be inappropriate.

Communication Communication with Medical Directionwith Medical Direction

Call location and informationCall location and information En route to scene/patientEn route to scene/patient Arrival at the scene/patientArrival at the scene/patient En route to hospitalEn route to hospital

(Continued)(Continued)

Communication Communication with Dispatchwith Dispatch

At hospitalAt hospital Leaving hospitalLeaving hospital Unusual situationsUnusual situations Request for assistance Request for assistance

Communication Communication with Dispatchwith Dispatch

Listen before transmitting.Listen before transmitting.

Press “Push to Talk” (PTT) buttonPress “Push to Talk” (PTT) buttonone second before speaking.one second before speaking.

Speak slowly and clearly.Speak slowly and clearly.

(Continued)(Continued)

Communication PrinciplesCommunication Principles

Avoid slang, codes, and profanity.Avoid slang, codes, and profanity.

Do not give a patient's name overDo not give a patient's name overthe air.the air.

Provide nonjudgmental, objectiveProvide nonjudgmental, objectiveinformation.information.

Communication PrinciplesCommunication Principles

Presents patient informationPresents patient informationto hospital.to hospital.

Allows hospital time to prepare.Allows hospital time to prepare. High-quality report “paints aHigh-quality report “paints a

picture” of the patient with picture” of the patient with words.words.

Radio ReportRadio Report

Unit and level of providerUnit and level of provider

Estimated time of arrivalEstimated time of arrival

PatientPatient’s age and sexs age and sex

Chief complaintChief complaint

(Continued)(Continued)

Radio Report: ContentRadio Report: Content

Brief, pertinent history ofBrief, pertinent history ofpresent illnesspresent illness

Major past illnessesMajor past illnesses

Mental statusMental status

Vital signsVital signs(Continued)(Continued)

Radio Report: ContentRadio Report: Content

Pertinent findings of thePertinent findings of thephysical examphysical exam

Emergency medical care givenEmergency medical care given Response to emergency medical Response to emergency medical care care

Radio Report: ContentRadio Report: Content

Introduce the patient by name.Introduce the patient by name. Summarize information fromSummarize information from

the radio report.the radio report.

Verbal CommunicationVerbal Communicationat the Hospitalat the Hospital

radio report.radio report. Update what has changed sinceUpdate what has changed since

DDOCUMENTATIONOCUMENTATION

Continuity of careContinuity of care Legal documentLegal document Quality improvementQuality improvement EducationEducation BillingBilling Statistics and researchStatistics and research

Prehospital Care Prehospital Care Report: FunctionsReport: Functions

Each piece of information is Each piece of information is an element.an element.

Minimum elements have beenMinimum elements have beenestablished for a PCRestablished for a PCR

(Continued)(Continued)

PCR Minimum Data SetPCR Minimum Data Set

Standardized definitionsStandardized definitionsfor elementsfor elements

Aids in researchAids in research

(Continued)(Continued)

PCR Minimum Data SetPCR Minimum Data Set

• 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 PCR Minimum Data Set Patient InformationPatient Information

• 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 PCR Minimum Data Set Administrative InformationAdministrative Information

PCR Run DataPCR Run Data

PCR Patient DataPCR Patient Data

PCR Check BoxesPCR Check Boxes

Avoid conclusions — be objective.Avoid conclusions — be objective. Include observations of the scene.Include observations of the scene. Include pertinent negatives.Include pertinent negatives. Avoid slang and radio codes.Avoid slang and radio codes. Use only standard abbreviations.Use only standard abbreviations. Use correct spelling.Use correct spelling.

PCR NarrativePCR Narrative

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.

PPRECEPTOR RECEPTOR PPEARLEARL

ConfidentialityConfidentiality

Distribution of copiesDistribution of copies

PCRPCR

May lead to revocation ofMay lead to revocation ofcertification/license.certification/license.

Leads to poor patient Leads to poor patient care.care.

(Continued)(Continued)

Falsification of PCRFalsification of PCR

If an error in patient care If an error in patient care

Note steps taken (if any) toNote steps taken (if any) to correct the situation. correct the situation.

occurs, document what didoccurs, document what didor didnor didn’t happen. t happen.

Falsification of PCRFalsification of PCR

Correction of Errors on PCRCorrection of Errors on PCR

Draw a single horizontal Draw a single horizontal ..

Write correct information Write correct information

Do not obliterate the Do not obliterate the

line through the error.line through the error.

beside it.beside it.

error.error.(Continued)(Continued)

• Use different color of ink.Use different color of ink.

• Correct error with single-line cross Correct error with single-line cross

• Initial and date the correction.Initial and date the correction.

If an error is discovered afterIf an error is discovered afterform is submitted:form is submitted:

out.out.

Correction of Errors on PCRCorrection of Errors on PCR

Competent adult patients Competent adult patients may legally refuse treatment.may legally refuse treatment.

Patients must be informed Patients must be informed of the consequences of refusingof the consequences of refusing

care.care.

(Continued)(Continued)

Patient RefusalPatient Refusal

Try to persuade the patient toTry to persuade the patient toaccept care and transportation.accept care and transportation.

Make sure the patient can Make sure the patient can make an informed, rational make an informed, rational decision.decision.

(Continued)(Continued)

Patient RefusalPatient Refusal

Document all assessment Document all assessment

Have patient sign refusal form.Have patient sign refusal form.

Have witness sign refusal form.Have witness sign refusal form.

findings.findings.

(Continued)(Continued)

Patient RefusalPatient Refusal

Document your attempts toDocument your attempts toconvince patient to go to hospital.convince patient to go to hospital.

Document actions taken to Document actions taken to protect patient after you leave.protect patient after you leave.

Contact medical direction if Contact medical direction if necessary.necessary.

Patient RefusalPatient Refusal

Insufficient time to fullyMCIMCIcomplete a PCR

Use local forms or “tags” onthe scene.

Follow local MCI plan fordocumentation.

Special ReportingSpecial ReportingSituationsSituations

Document unusual events.Document unusual events.

Document injury or exposure.Document injury or exposure.

Supplement or amplify Supplement or amplify primary reports.primary reports.

Special Situation ReportsSpecial Situation Reports

1. List the required elements of a radio1. List the required elements of a radio report.report.

2. Describe ways to improve interpersonal2. Describe ways to improve interpersonal communication.communication.

RREVIEW QUESTIONSEVIEW QUESTIONS