Chapter 4- Communications And Documentation Flashcards
Communication
The transmission of information to another person, verbally or nonverbally
Documentation
The written or electronically recorded portion of your patient care interaction that becomes part of the patients permanent medical record
Therapeutic communication
Uses various communication techniques and strategies, both verbal and nonverbal, to encourage patients to express how they are feeling and to achieve a positive relationship with the patient
Factors and strategies to consider during communication
Age, body language, clothing, culture, education, environment, eye contact, facial expression, gender, posture, voice tempo, volume
What is the Shannon weaver communication model
It was developed to assist in a mathematical theory of communication (figuring out the math involved in sending information to telephone lines)
Ethnocentrism
Putting your own cultural values as more important when you were interacting with people of a different culture
Cultural imposition
when one person imposes his or her beliefs, values, and practices on another because here she believes his ideas are superior
What steps can you take to diffuse a situation with an angry person?
- Assess the safety of the scene (law enforcement needs)
- Do not assume an aggressive posture
- Make good eye contact, but do not stare
- Speak calmly, confidently, and slowly
- Never threaten the patient, either verbally or physically
Noise
Anything the dampens or obscures the true meaning of the message
Define distance of personal space for intimate, personal, social, and public
Intimate: less than 18 inches, whispering touching must be invited
Personal: 18 in. to 4 feet, Conversations with close friends or family
Social: 4 feet to 10 feet, conversations with acquaintances
Public: 10 feet to 25 feet, interacting with strangers
Open ended questions
Questions that the patient needs to provide some level of detail to give an answer
closed ended questions
And be answered with a very short response
What are the 10 golden rules to help calm and reassure your patient and provided therapeutic rapport
- Make and keep eye contact with the patient at all times
- Provide your name and use the patients proper name
- Tell the patient the truth
- Use language that the patient can understand
- Be careful what you say about the patient to others
- Be aware of your body language
- Always speak slowly, clearly, and distinctly
- If the patient is hard of hearing, faced a person so that he or she can read your lips
- Allow time for the patient to answer or respond to your questions
- Act and speak in a calm, confident manner while caring for the patient
Rapport
Building a trusting relationship with your patient
What are five steps you can initiate to efficiently communicate with patients who are hard of hearing
- I have a paper and pen available
- If the patient can read lips, you should face the patient and speak slowly and distinctly
- Never shout
- Be sure to listen carefully, ask certain questions, give short answers
- Learn some simple phrases in sign language
What six components must be included in the oral report
- Opening information (patients name, chief complaint, NOI or MOI)
- Detailed information that was not provided during the radio report
- Any important history
- The patient’s response treatment given en route
- Vital signs assessed during transport and after the radio report
- Other information you may have gathered that was not important enough to report sooner
Patient care report (prehospital care report)
The legal document used to record all aspects of the care your patient received, from initial dispatch to arrival at the hospital
The patient care report serves the following six functions
- Continuity of care
- Legal documentation
- Education
- Administrative information
- Essential research record
- Evaluation and continuous quality improvement
The narrative section of the PCR needs to include the following information
Time of events Assessment findings emergency medical care provided Changes in the patient after treatment Final patient disposition Observations at the scene Refusal of care Staff person who continued care
What does SOAP stand for?
Subjective, objective, assessment, and patient care
What does CHART or CHARTE stand for
Chief complaint, history and physical examination, assessment, treatment, and transport
Base station
A base station is any radio hardware containing a transmitter and receiver that is located in a fixed place
Channel
An assigned frequency or frequencies used to carry voice and or data communications
Dedicated line (hotline)
Used for specific point to point contact
VHF (Very high frequency)
Mobile radios operating between 30 and 300 MHz
UHF(ultra high frequency)
Radios that operate between 300 MHZ and 3000 MHZ
Portable radios
Handheld devices that operate at 1 to 5 W of power
Repeater
Especial base station radio that receives messages and signals on one frequency and then automatically retransmits them on a second frequency
Telemetry
Electronic signals are converted into coded, audible signals
Cellular telephone
These telephones are simply low powered portable radios that communicate through a series of interconnected repeater stations called cells
Simplex
Push to talk, release to listen
Duplex system
Simultaneous talk and listen. Communications on UHF frequencies and cellular telephones
Multiplex
This design utilizes two or more frequencies, which enables more than one transmission to occur simultaneously and provides for transmission of both audio and data signals via deprecate channels
MED channels
Are reserved exclusively for EMS use
Trunking
800 MHz Systems where are many frequencies are assigned to a group
Interoperable communication system
Allows all of the agencies involved to share a valuable information with each other in real time
Mobile data terminal (MDT)
A small computer terminal inside the ambulance that directly receives data from the dispatch center
Federal Communications Commission
Has jurisdiction over interstate in international telephone and telegraph services and satellite communications
Standing orders
Written documents that I’ve been signed by the EMS Systems medical director
