Chapter 4 - Communications and Documentation Flashcards

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1
Q

Communication

A

Tranmission of information to one another

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2
Q

Verbal Comm

A

speech - enables to gather critical info, coordinate with other responders, interaction with other health care professionals

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3
Q

Nonverbal comm

A

Body language, facial expressions, eye contact, gestures

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4
Q

Documentation for:

A
  • Patients permanent medical record
  • Demonstrates appropriate care was delivered
  • Helps other in patient’s future care
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5
Q

Complete patient records for:

A
  • Proper transfer of responsibility
  • Comply with requirements of health departments and law enforcement agencies
  • Fulfill your organization’s admin needs
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6
Q

Computer, radio, telephone comms that:

A

link emt to ems, fd, law enforcement
Don’t mention patient’s name as it violates HIPAA

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7
Q

Closed loop comm

A

Dialogue to a reply acknowledging it

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8
Q

Techniques to communicate *therapeutic

A
  • Verbal and nonverbal
  • Encourage patients to express how they feel
  • Achieve a positive relationship
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9
Q

Shannon-Weaver communication model

A
  • Sender takes thought
  • Encodes it to a message
  • Sends the message to the receiver
  • Receiver decodes it
  • Sends feedback to the sender
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10
Q

Etnocentrism

A

Considering your own cultural values more important than those of others

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11
Q

Cultural imposition

A

Forcing your values onto others

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12
Q

When dealing with a hostile patient

A
  • Assess safety of the situation
  • Don’t assume an aggressive language
  • Make good eye contact, but do not stare
  • Speak calmly, confidently, and slowly
  • Never threaten the patient
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13
Q

Physical factors that affect situations

A
  • Literal noises
  • Cultural norms
  • Non verbal comm
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14
Q

Open-ended questions

A

Require detail, fundamental to prehospital care (questions in general) - not used compared to close ended

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15
Q

Closed-ended questions

A

Short responses to help make it easier

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16
Q

Interviewing techniques

A
  • Touch to show caring and compassion(but not torso, chest, or face) - use consciously and sparingly
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17
Q

interviewing techniques to avoid

A
  • False assurance or reassurance
  • Unsolicited advice
  • Leading or biased ques
  • Overtalking
  • Interrupting
  • “Why” questions
  • Authoritative language
  • Speaking in professional jargon
18
Q

Golden rules to communicate with patients

A
  • Eye contact all times
  • Your name and use patient’s proper name
  • Always the truth
  • Understandable language
  • be careful what you say about the patient to others
  • Proper body language
  • Speak slowly, clearly, an distinctly
  • hard of hearing? Let them see you lips
19
Q

Emotional intelligence

A

Ability to manage and understand your emotions and properly respond to others’ emotions
- Helps to defuse conflict
- Build rapport
- Communication
- Difficult situation handling

20
Q

Attributes of Emotional Intelligence

A
  • Self awareness
  • Self regulation
  • Motivation
  • Empathy
  • Social skills
21
Q

Stairway for crisis management (Behavior change stairway model)

A
  • Employ active listening
  • Display empathy
  • Build a rapport
  • Exert influence
  • Initiate behavior change
22
Q

PCR

A

Patient care report: Used to record all aspects of the care your patient received

23
Q

Functions of PCR

A
  1. Continuity of care
  2. Compliance and legal documentation
  3. Administrative info
  4. Reimbursement
  5. Education
  6. Dat collection for CQI and research
24
Q

Info collected on the PCR

A
  • CC
  • MOI/NOI
  • LOC or Mental status
  • Vitals
  • Initial and ongoing assessment
  • Patient demographics
  • Transport info
25
Q

Acronyms for the PCR

A

SOAP and CHART

26
Q

SOAP

A

Subjective, Objective, Assessment, Plan

27
Q

CHART

A

C/C, History, Assessment, Rx/Treatment(OTC, Prescription, Illicit), Transport

28
Q

All narrative sections of PCR should have

A
  • time of events
  • Assessment findings
  • Emergency medical care provided
29
Q

Falsification

A
  • Results in poor patient care
  • Suspension/legal action possible
30
Q

Documenting refusal of care

A

HAVE PATIENT SIGN A REFUSAL OF CARE FORM AND A WITNESS TO SIGN AS WELL

31
Q

Special reporting situations

A

Depending on local requirements:
- Gunshot wounds
- Dog bites
- Some infectious diseases
- Suspected physical or sexual abuse
-

32
Q

Base station radios

A

In a fixed place where a two way radio consists of receiver and transmitter is present

33
Q

Mobile radios

A

To communicate with dispatcher and medical control

34
Q

Portable radios

A
35
Q

Repeater-based systems

A
36
Q

Digital equipment

A

With telemetry, electronic signals are converted into coded, …

37
Q

Cellular/Satellite telephones

A
38
Q

Other communications equipment

A
39
Q

Dispatcher (responding to the scene)

A
40
Q

Role of medical control

A

Either off line or online
May need permission for:
- Administering certain treatments
- Determination of transport destination
-