Chapter 4: Communications and Documentation Flashcards
List the factors and strategies to consider during communication.
- Age
- Body Language
- Clothing
- Culture
- Education
- Environment
- Eye Contact
- Facial Expression
- Sex
- Posture
- Voice Tempo
- Volume
List the information that should be included in a Patient Care Report (PCR).
- Patient’s name, gender, date of birth, address, insurance information
- Dispatched as (when ambulance was called, nature of call as reported by dispatch)
- Chief complain or chief concern
- Location of patient when first seen
- Rescue / treatment given prior to your arrival
- Signs / symptoms found during your assessment
- Care / treatment given by you at the site and during transport
- Vital signs
- SAMPLE History
- Changes in vital signs and condition
- Additional orders received from hospital
- Name of person receiving PCR
- Date of call
- Time of call
- Location of call
- Time of dispatch
- Time of arrival at scene
- Time of leaving the scene
- time of arrival at hospital
- Names / certification #s of EMTs who responded to call
- Type of run to the scene; emergency or routine
What phrase or word matches this definition?
Telecommunication systems that allow a computer to maximize utilization of a group of frequencies.
Trunking
What phrase or word matches this definition?
The transmission of information to another person- verbally or through body language.
Communication
What phrase or word matches this definition?
The use of a radio signal and a voice or digital message that is transmitted to pagers or desktop monitor radios.
Paging
Define the following emotional intelligence attribute.
Self-Awareness
The ability to recognize your own emotions and how they affect your thoughts and behavior.
What phrase or word matches this definition?
The transfer of pertinent patient information and the responsibility for the patient’s care; often involves the physical movement of the patient and associated equipment; also known as handoff.
Handover
What should the narrative section of the PCR include?
- Time of events
- Assessment findings
- Emergency medical care provided
- Changes in the patient after treatment
- Observations at the scene
- Final patient disposition
- Refusal of care
- Staff person who continued care
What phrase or word matches this definition?
The recorded portions of the EMT’s patient interaction, either written or electronic. This becomes part of the patient’s permanent medical record.
Documentation
What phrase or word matches this definition?
Questions that can be answered in short or single word responses.
Close-Ended Questions
What phrase or word matches this definition?
The ability to understand and manage one’s own emotions and properly respond to the emotions of others.
Emotional Intelligence
How should the EMS unit communicate during this phase?
On Scene
Report arrival at scene.
Check in (typically every 10-20 minutes).
Request additional resources, when needed.
Report leaving scene.
When treating a potentially hostile patient, what steps should an EMT consider following?
- Assess the safety of the scene.
- Do not assume an agressive posture.
- Make good eye contact, but do not stare.
- Speak calmly, confidently, and slowly.
- Never threaten the patient, either verbally or physically.
Define the following therapeutic communication technique.
Summary
Providing the patient with an overview of the conversation and the steps you will take.
List tips for communicating with non-English speakers.
- Find out how much English the patient speaks.
- Use short, simple questions and words.
- Avoid difficult medical terms.
- Point to specific parts of the body as you ask questions.
- Use an app to help you translate.
- Find an interpreter.
- Make sure to request a translator in your radio report.
What role does the National Emergency Medical Services Information System (NEMSIS) play?
Conducts research on data collected linking prehospital records to hospital discharge outcomes explanding the knowledge base about what EMS providers actually do on a day-to-day basis and on what treament measures really make a difference.
What phrase or word matches this definition?
Single-frequency radio; transmissions can occur in either direction but not simultaneously in both; when one party transmits, the other can only receive, and the party that is transmitting is unable to receive.
Simplex
What phrase or word matches this definition?
The ability to transmit and receive simultaneously.
Duplex
What phrase or word matches this definition?
A low-power portable radio that communicates through an interconnected series of repeater stations called “cells.”
Cellular Telephone
What does the acronym mean?
MDT
Mobile Data Terminal
How should the EMS unit communicate during this phase?
En Route to Call
Request assistance with directions, when needed.
Request additional resouces, when needed.
What six functions does a patient care report (PCR) serve?
- Transfer of information and continuity of care.
- Compliance and legal documentation.
- Administrative information.
- Reimbursement.
- Education.
- Data collection for quality improvement and research.
How should the EMS unit communicate during this phase?
Initial Receipt of Call
Acknowledge Call
Respond to the Call
Define the following therapeutic communication technique.
Empathy
Being sensitive to the patient’s feelings and thoughts.
Define the following therapeutic communication technique.
Interpretation
Restate the patient’s concern (a.k.a. complaint) to confirm your understanding.
What does the term “functional age” mean?
Functional age relates to a person’s ability to function in daily activities, mental state, health status, and activity pattern.
What phrase or word matches this definition?
Any communications where disruption will result in the failure of the mission at hand.
Mission-Critical Communications
What phrase or word matches this definition?
A process in which electronic signals are converted into coded, audible signals; these signals can then be transmitted by radio or telephone to a receiver with a decoder at the hospital.
Telemetry
Define the following emotional intelligence attribute.
Empathy
The ability to understand the concerns, emotions, and needs of other by picking up on communication and social cues and clues.
List tips for communicating with a visually impaired patient.
- Ask patient what their level of eye sight is.
- Explain everything in detail.
- Keep physical contact with patient. Keep hand on shoulder when possible.
- Avoid sudden movements.
- Be sure to transport any items (i.e. cane).
- Bring guide dog in ambulance if patient is stable. If unstable, care for dog per department policies / procedures.
What phrase or word matches this definition?
This legal document used to record all patient care activities. This report has direct patient care functions but also administrative and quality control functions; also known as prehospital care reports.
Patient Care Report (PCR)
What phrase or word matches this definition?
When one person imposes their beliefs, values, and practices on another because one believes their ideals is superior.
Cultural Imposition
Define the following therapeutic communication technique.
Confrontation
Making the patient who is in denial or having an acute stress response focus on urgent and life-critical issues.
Define the following therapeutic communication technique.
Pause
Giving the patient space and time to think and respond by refraining from speaking.
What phrase or word matches this definition?
Written documents, signed by the EMS system’s medical director, that outline specific directions, permissions, and sometimes prohibitions regarding patient care; also called protocols.
Standing Orders
What phrase or word matches this definition?
Anything that dampens or obscures the true meaning of a message.
Noise