Chapter 4 - Communications and Documentation Flashcards
Communication
Tranmission of information to one another
Verbal Comm
speech - enables to gather critical info, coordinate with other responders, interaction with other health care professionals
Nonverbal comm
Body language, facial expressions, eye contact, gestures
Documentation for:
- Patients permanent medical record
- Demonstrates appropriate care was delivered
- Helps other in patient’s future care
Complete patient records for:
- Proper transfer of responsibility
- Comply with requirements of health departments and law enforcement agencies
- Fulfill your organization’s admin needs
Computer, radio, telephone comms that:
link emt to ems, fd, law enforcement
Don’t mention patient’s name as it violates HIPAA
Closed loop comm
Dialogue to a reply acknowledging it
Techniques to communicate *therapeutic
- Verbal and nonverbal
- Encourage patients to express how they feel
- Achieve a positive relationship
Shannon-Weaver communication model
- Sender takes thought
- Encodes it to a message
- Sends the message to the receiver
- Receiver decodes it
- Sends feedback to the sender
Etnocentrism
Considering your own cultural values more important than those of others
Cultural imposition
Forcing your values onto others
When dealing with a hostile patient
- 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
Physical factors that affect situations
- Literal noises
- Cultural norms
- Non verbal comm
Open-ended questions
Require detail, fundamental to prehospital care (questions in general) - not used compared to close ended
Closed-ended questions
Short responses to help make it easier
Interviewing techniques
- Touch to show caring and compassion(but not torso, chest, or face) - use consciously and sparingly
interviewing techniques to avoid
- False assurance or reassurance
- Unsolicited advice
- Leading or biased ques
- Overtalking
- Interrupting
- “Why” questions
- Authoritative language
- Speaking in professional jargon
Golden rules to communicate with patients
- 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
Emotional intelligence
Ability to manage and understand your emotions and properly respond to others’ emotions
- Helps to defuse conflict
- Build rapport
- Communication
- Difficult situation handling
Attributes of Emotional Intelligence
- Self awareness
- Self regulation
- Motivation
- Empathy
- Social skills
Stairway for crisis management (Behavior change stairway model)
- Employ active listening
- Display empathy
- Build a rapport
- Exert influence
- Initiate behavior change
PCR
Patient care report: Used to record all aspects of the care your patient received
Functions of PCR
- Continuity of care
- Compliance and legal documentation
- Administrative info
- Reimbursement
- Education
- Dat collection for CQI and research
Info collected on the PCR
- CC
- MOI/NOI
- LOC or Mental status
- Vitals
- Initial and ongoing assessment
- Patient demographics
- Transport info
Acronyms for the PCR
SOAP and CHART
SOAP
Subjective, Objective, Assessment, Plan
CHART
C/C, History, Assessment, Rx/Treatment(OTC, Prescription, Illicit), Transport
All narrative sections of PCR should have
- time of events
- Assessment findings
- Emergency medical care provided
Falsification
- Results in poor patient care
- Suspension/legal action possible
Documenting refusal of care
HAVE PATIENT SIGN A REFUSAL OF CARE FORM AND A WITNESS TO SIGN AS WELL
Special reporting situations
Depending on local requirements:
- Gunshot wounds
- Dog bites
- Some infectious diseases
- Suspected physical or sexual abuse
-
Base station radios
In a fixed place where a two way radio consists of receiver and transmitter is present
Mobile radios
To communicate with dispatcher and medical control
Portable radios
Repeater-based systems
Digital equipment
With telemetry, electronic signals are converted into coded, …
Cellular/Satellite telephones
Other communications equipment
Dispatcher (responding to the scene)
Role of medical control
Either off line or online
May need permission for:
- Administering certain treatments
- Determination of transport destination
-
