9: Communications and Documentation
Cognitive Objectives (1 of 5)
3-7.1 List proper methods of initiating and terminating
a radio call.
3-7.2 State proper sequence for delivery of patient
information.
3-7.3 Explain the importance of effective
communication of patient information in the verbal
report.
3-7.4 Identify the essential components of the verbal
report.
Cognitive Objectives (2 of 5)
3-7.5 Describe attributes for increasing effectiveness and
efficiency of verbal communications.
3-7.6 State legal aspects to consider in verbal
communication.
3-7.7 Discuss the communication skills that should be
used to interact with the patient.
Cognitive Objectives (3 of 5)
3-7.8 Discuss the communication skills that should be
used to interact with the family, bystanders, and
individuals from other agencies while providing
patient care and hospital personnel, and the
difference between skills used to interact with the
patient and those used to interact with others.
3-7.9 List the correct radio procedures in the following
phases of a typical call: to the scene, at the scene,
to the facility, at the facility, to the station, at the
station.
Cognitive Objectives (4 of 5)
3-8.1 Explain the components of the written report and
list the information that should be included on the
written report.
3-8.2 Identify the various sections of the written report.
3-8.3 Describe what information is required in each
section of the prehospital care report and how it
should be entered.
3-8.4 Define the special considerations concerning
patient refusal.
Cognitive Objectives (5 of 5)
3-8.5 Describe the legal implications associated with the
written report.
3-8.6 Discuss all state and/or local record and reporting
requirements.
Affective Objectives
3-7.10 Explain the rationale for providing efficient and
effective radio communications and patient reports.
3-8.7 Explain the rationale for patient care
documentation.
3-8.8 Explain the rationale for the EMS system gathering
data.
3-8.9 Explain the rationale for using medical terminology
correctly.
Psychomotor Objectives
3-7.11 Perform a simulated, organized, concise radio
transmission.
3-7.12 Perform an organized, concise patient report
that would be given to the staff at a receiving
facility.
3-7.13 Perform a brief, organized report that would be
given to an ALS provider arriving at an incident
scene at which the EMT-B was already providing
care.
3-8.11 Practice completing a prehospital care report.
Communications and Documentation
• Essential components of prehospital care:
– Verbal communications are vital.
– Adequate reporting and accurate records ensure
continuity of patient care.
– Reporting and record keeping are essential aspects
of patient care.
Base Station Radios
• Transmitter and receiver located in a fixed place
• Power of 100 watts or more
• A dedicated line (hot line) is always open.
– Immediately “on” when you lift up the receiver
Mobile and Portable Radios
• Mobile radios installed in vehicle
– Range of 10 to 15 miles
• Portable radios hand-held
– Operate at 1 to 5 watts of power
Repeater-Based Systems
• Receives radio messages and retransmits
• A repeater is a base station able to receive low-power
signals.
Digital Equipment
• Some EMS systems use telemetry to send an ECG
from the unit to the hospital.
• Telemetry is the process of converting electronic
signals into coded, audible signals.
• Signals can be decoded by the hospital.
Cellular Telephones
• Low-powered portable radios that communicate
through interconnected repeater stations
• Cellular telephones can be easily scanned.
Other
• Simplex
– Push-to-talk communication
• Duplex
– Simultaneous talk-listen
• MED channels
– Reserved for EMS
Communication Quality
• Affected by power and location of antennas
• Changes in location can affect quality of transmission
• Check communication equipment at beginning of each
shift.
FCC Duties
• Allocate radio frequencies
• License base stations and assign call signs.
• Establish licensing standards and operating
specifications
• Establish limits on transmitter power output
• Monitor radio operations
Dispatch Responsibilities
• Screen and assign priorities
• Select and alert appropriate units to respond
• Dispatch and direct units to the location
• Coordinate response with other agencies
• Provide pre-arrival instructions to the caller
Information Received
from Dispatch
•
•
•
•
•
•
Nature and severity of injury, illness, or incident
Location of incident
Number of patients
Responses by other agencies
Special information
Time dispatched
Communicating With Dispatch
• Report any problems during
run.
• Advise of arrival.
• Communicate scene size-up.
• Keep communications brief.
Insert EMTB9e Fig.
9-4.
Communicating
With Medical Control
• Radio communications facilitate contact between
providers and medical control.
• Consult with medical control to:
– Notify hospital of incoming patient.
– Request advice or orders.
– Advise hospital of special circumstances.
• Organize your thoughts before transmitting.
Patient Report
• Identification and level of services
• Receiving hospital and ETA
• Patient’s age and gender
• Chief complaint
• History of current problem
• Physical findings
• Summary of care given and patient response
Role of Medical Control
•
•
•
•
May be off-line or online
Guides treatment of patients
May have to contact directly for orders
Many variations from system to system
Calling Medical Control
• Physician bases his or her instructions on report
received from the EMT-B.
• Never use codes while communicating.
• Repeat all orders received.
• Do not blindly follow an order that does not make
sense to you.
Special Situations
• Notify as early as possible.
• Estimate the potential number of patients.
• Identify special needs.
Standard Procedures and Protocols
• Keep transmission brief.
• Develop effective radio discipline.
• Identify the called unit, followed
by the calling unit.
– “Dispatch, this is Medic One.”
Reporting Requirements
• Acknowledge dispatch information.
• Notify arrival at scene.
• Notify departure from scene.
• Notify arrival at hospital or facility.
• Notify you are clear of the incident.
• Notify arrival back in quarters.
Maintenance of Equipment
• Radio equipment must be properly serviced.
• Nonfunctioning equipment should be removed from
service.
• Backup plans should be in place in case of
communication failure.
• Standing orders: Written documents signed by the
EMS system’s medical director.
Verbal Communication
• Essential part of quality patient care
• You must be able to find out what the patient needs
and then tell others.
• You are a vital link between the patient and the health
care team.
Components of an Oral Report
• Patient’s name, chief complaint, nature of illness,
mechanism of injury
• Summary of information from radio report
• Any important history not given earlier
• Patient’s response to treatment
• The vital signs assessed
• Any other helpful information
Communicating With Patients (1 of 2)
• Make and keep eye contact.
• Use the patient’s proper name.
• Tell the patient the truth.
• Use language the patient can understand.
• Be careful of what you say about the patient to
others.
Communicating With Patients (2 of 2)
• Be aware of your body language.
• Always speak slowly, clearly, and distinctly.
• If the patient is hearing impaired, speak clearly and
face him or her.
• Allow time for the patient to answer questions.
• Act and speak in a calm, confident manner.
Communicating With Geriatric
Patients
• Determine the person’s functional age.
• Do not assume that an older patient is senile or
confused.
• Allow patient ample time to respond.
• Watch for confusion, anxiety, or impaired hearing or
vision.
• Explain what is being done and why.
Communicating With Children
• Children are aware of what is
going on.
• Allow people or objects that
provide comfort to remain close.
• Explain procedures to children
truthfully.
• Position yourself on their level.
Communicating With HearingImpaired Patients
• Always assume that the patient has normal
intelligence.
• Make sure you have a paper and pen.
• Face the patient and speak slowly, clearly and
distinctly.
• Never shout!
• Learn simple phrases used in sign language.
Communicating With VisionImpaired Patients
• Ask the patient if he or she can see at all.
• Explain all procedures as they are being performed.
• If a guide dog is present, transport it also, if possible.
Communicating With Non-EnglishSpeaking Patients
• Use short, simple questions and answers.
• Point to specific parts of the body as you ask
questions.
• Learn common words and phrases in the non-English
languages used in your area.
Written Written
Communication
and Documentation and
Communication
Documentation
Minimum Data Set (1 of 2)
• Patient information
– Chief complaint
– Mental status
– Systolic BP (patients older than 3 years)
– Capillary refill (patients younger than 6 years)
– Skin color and temperature
– Pulse
– Respirations and effort
Minimum Data Set (2 of 2)
•
•
•
•
•
•
Time incident was reported
Time that EMS unit was notified
Time EMS unit arrived on scene
Time EMS unit left scene
Time EMS unit arrived at facility
Time that patient care was transferred
Functions of the Prehospital
Care Report
• Prehospital care report serves six functions
– Continuity of care
– Legal documentation
– Education
– Administrative
– Research
– Evaluation and quality improvement
Types of Forms
• Written forms
• Computerized versions
• Narrative sections of the form
– Use only standard abbreviations.
– Spell correctly.
– Record time with assessment findings.
• Report is considered confidential.
Reporting Errors
• Do not write false statements on report.
• If error made on report then:
– Draw a single horizontal line through error.
– Initial and date error.
– Write the correct information .
Documenting Right of Refusal
•
•
•
•
Document assessment findings and care given.
Have the patient sign the form.
Have a witness sign the form.
Include a statement that you explained the possible
consequences of refusing care to the patient.
Special Reporting Situations
• Be familiar with required reporting in your jurisdiction,
including:
– Gunshot wounds
– Animal bites
– Certain infectious diseases
– Suspected physical, sexual, or substance abuse
– Multiple-casualty incidents (MCI)
Effective Communication
Review
1. A device that receives a low frequency and then
transmits it at a relatively higher frequency is called a:
A. duplex.
B. scanner.
C. repeater.
D. receiver.
Review
Answer: C
Rationale: A repeater receives messages and
frequencies from one frequency and then
automatically transmits them on a second, higher
frequency.
Review
1. A device that receives a low frequency and then transmits it at a
relatively higher frequency is called a:
A. duplex.
Rationale: Duplex is the ability to transmit and receive messages
simultaneously.
B. scanner.
Rationale: This is a device that searches or scans across several
frequencies until a message is completed.
C. repeater.
Rationale: Correct answer
D. receiver.
Rationale: This is a device that only receives and does not transmit.
Review
2. All of the following are functions of the emergency
medical dispatcher, EXCEPT:
A. alerting the appropriate EMS response unit.
B. screening a call and assigning it a priority.
C. providing emergency medical instructions to the caller.
D. providing medical direction to the EMT-B in the field.
Review
Answer: D
Rationale: Functions of the emergency medical
dispatcher (EMD) include screening a call and
assigning it a priority, alerting the appropriate EMS
response unit, coordinating EMS units with other
public safety services, and providing prearrival
emergency medical instructions to the caller.
Review
2. All of the following are functions of the emergency medical
dispatcher, EXCEPT:
A. alerting the appropriate EMS response unit.
Rationale: The dispatcher notifies the closest appropriate EMS unit.
B. screening a call and assigning it a priority.
Rationale: The dispatcher prioritizes incoming calls.
C. providing emergency medical instructions to the caller.
Rationale: The dispatcher helps callers with medical instructions.
D. providing medical direction to the EMT-B in the field.
Rationale: Correct answer
Review
3. The success of communications depends on the:
A. location of the hospital.
B. strength of your voice.
C. efficiency of the equipment.
D. strength of the microphone.
Review
Answer: C
Rationale: A number of factors affect communication
effectiveness; however, the efficiency of the equipment
you are using ultimately affects the success of
communications.
Review
3. The success of communications depends on the:
A. location of the hospital.
Rationale: The hospital location has no influence on how successful
communication it is.
B. strength of your voice.
Rationale: This is important, but it has no impact on a successful
communication.
C. efficiency of the equipment.
Rationale: Correct answer
D. strength of the microphone.
Rationale: The microphone is only one piece of equipment needed
for successful communication.
Review
4. After receiving an order from medical control over the
radio, the EMT-B 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.
Review
Answer: D
Rationale: After receiving an order from medical control,
the EMT-B 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-B should obtain the necessary consent
from the patient.
Review
4. After receiving an order from medical control over the radio, the
EMT-B should:
A. carry out the order immediately.
Rationale: The order must be repeated back first to confirm that it
was heard correctly.
B. disregard the order if it is not understood.
Rationale: Repeating the order will help the EMT to clarify any
misunderstandings.
C. obtain the necessary consent from the patient.
Rationale: This step is carried out after the order has been
confirmed and understood by the EMT.
D. repeat the order to the physician word for word.
Rationale: Correct answer
Review
5. Who is ultimately responsible for all patient care
related activities at a mass-casualty incident?
A. Incident commander
B. EMS medical director
C. Senior EMT-B at the scene
D. EMS operations supervisor
Review
Answer: B
Rationale: The incident commander (IC) maintains
general command and control over a mass-casualty
incident; however, the EMS medical director is
ultimately responsible for all patient care related
activities. The IC—or his or her designee—should
confer with medical control as needed.
Review
5. Who is ultimately responsible for all patient care related activities at a
mass-casualty incident?
A. Incident commander
Rationale: The incident commander, responsible for general command
over a multi-causality incident, confers with the medical director.
B. EMS medical director
Rationale: Correct answer
C. Senior EMT-B at the scene
Rationale: The senior EMT-B will usually handle another position at a
multi-casualty incident, typically the triage officer.
D. EMS operations supervisor
Rationale: The EMS operations supervisor is not responsible for patient
care, but will usually work with the incident commander as part of the
overall operations.
Review
6. Which of the following statements about the
prehospital care report 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
Review
Answer: C
Rationale: The prehospital care report (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 EMTB.
Review
6. Which of the following statements about the prehospital care
report is true?
A. It is not a legal document in the eyes of the law
Rationale: A prehospital care report is a legal document.
B. It cannot be used for patient billing information
Rationale: A prehospital care report can be used by hospital
administration which includes the billing department.
C. It helps ensure efficient continuity of patient care
Rationale: Correct answer
D. It is for use only by the prehospital care provider
Rationale: While it may not be read immediately by the hospital, it
can be used later to review patient care procedures and for
quality improvement purposes.
Review
7. When requesting medical direction for a patient who
was involved in a major car accident, the EMT-B
should avoid:
A. using radio codes to describe the situation.
B. questioning an order that seems inappropriate.
C. relaying vital signs unless they are abnormal.
D. the use of medical terminology when speaking.
Review
Answer: A
Rationale: When giving a report to medical control or
requesting medical direction, the EMT-B should avoid
the use of codes, such as “10-50” or “Signal 70.” One
cannot assume that the physician is familiar with these
codes. Plain English is more effective.
Review
7. When requesting medical direction for a patient who was involved
in a major car accident, the EMT-B should avoid:
A. using radio codes to describe the situation.
Rationale: Correct answer
B. questioning an order that seems inappropriate.
Rationale: If an order seems inappropriate, EMS providers must
question the validity of the order.
C. relaying vital signs unless they are abnormal.
Rationale: Vital signs are necessary to describe the patient’s
condition to the medical director.
D. the use of medical terminology when speaking.
Rationale: The use of appropriate medical terminology shows the
EMS provider’s confidence, knowledge, and expertise to the
medical director.
Review
8. Which of the following pieces of patient information is
of LEAST pertinence when giving a verbal report to a
nurse or physician at the hospital?
A. The patient's name and age
B. The patient's family medical history
C. Vital signs that may have changed
D. Medications that the patient is taking
Review
Answer: B
Rationale: Information given to the receiving nurse or
physician should include the patient's name and age,
vital signs (especially if they have changed), a
summary of the past medical history, and the patient's
response to any treatment that you rendered. Family
medical history is not essential in the emergency
treatment of a patient.
Review
8. Which of the following pieces of patient information is
of LEAST pertinence when giving a verbal report to a
nurse or physician at the hospital?
A. The patient's name and age
Rationale: This is very important in a verbal report.
B. The patient's family medical history
Rationale: Correct answer
C. Vital signs that may have changed
Rationale: This is very important in a verbal report.
D. Medications that the patient is taking
Rationale: This is very important in a verbal report.
Review
9. When communicating with an elderly patient, you
should:
A. approach the patient slowly and calmly.
B. step back to avoid making the patient uncomfortable.
C. raise your voice to ensure that the patient can hear
you.
D. obtain the majority of your information from family
members.
Review
Answer: A
Rationale: Approach an elderly patient slowly and calmly,
use him or her as your primary source of information
whenever possible, and allow ample time for the
patient to respond to your questions. Not all elderly
patients are hearing impaired; if the patient is hearing
impaired, you may need to elevate your voice slightly.
Review
9. When communicating with an elderly patient, you should:
A. approach the patient slowly and calmly.
Rationale: Correct answer
B. step back to avoid making the patient uncomfortable.
Rationale: You may need to get closer. You have to touch the
patient to take vital signs.
C. raise your voice to ensure that the patient can hear you.
Rationale: Not all elderly patients are hearing impaired.
D. obtain the majority of your information from family members.
Rationale: Always speak to the patient, the patient’s responses can
provide unlimited information.
Review
10. While caring for a 5-year-old boy with respiratory
distress, you should:
A. avoid direct eye contact with the child, as this may
frighten him.
B. avoid letting the child hold any toys, as this may
hinder your care.
C. realize that it is usually easy to deceive a child when
treating them.
D. allow a parent or caregiver to hold the child if the
situation allows.
Review
Answer: D
Rationale: When caring for children, take special care to
avoid upsetting them. Allowing a parent to hold the
child or allowing the child to play with a favorite toy
often helps to keep the child calm. Never lie to a child,
or any other patient for that matter; children can see
through lies and deceptions. Assure the child that you
can be trusted and are there to help by maintaining
eye contact.
Review
10. While caring for a 5-year-old boy with respiratory distress, you
should:
A. avoid direct eye contact with the child, as this may frighten him.
Rationale: Eye contact helps to establish trust with children.
B. avoid letting the child hold any toys, as this may hinder your care.
Rationale: Playing with a toy can calm a child and keep the child
occupied.
C. realize that it is usually easy to deceive a child when treating
them.
Rationale: Never lie to a child, children can detect deception.
D. allow a parent or caregiver to hold the child if the situation allows.
Rationale: Correct answer
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Chapter 36 Gaining Access