Chapter 4- Communications and Documentation Flashcards by Jenna Lukes

documentation: defined as the … or … recorded part of the patient’s permanent medical record

written; electronically

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complete patient records:
guarantee proper … of responsibility
comply with requirements of … and … agencies
fulfill your organizations’ administrative needs

transfer; health departments; law enforcement

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radio and telephone communications link you to other members of the …, the …, and … communities

EMS; fire dept; law enforcement

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therapeutic communication uses various communication techniques and strategies; both verbal and nonverbal, encourages patients to express …, achieves a … relationship with patients

how they feel; positive

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Shannon-Weaver communication model: developed to assist in the mathematical theory of communication for Bell Telephone Labs: 
sender takes a ... 
encodes it into a ..
sends the message to the ... 
receiver ... the message
sends ... to the sender

thought; message; receiver; decodes; feedback

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considering your own cultural values more important than those of others: …

ethnocentrism

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forcing your values onto others: …

cultural imposition

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…: anything that dampens or obscures true meaning of message

noise

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… questions require some level of detail in the response

open-ended

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…can be answered in very short responses

Closed-ended questions

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tone, pace, and volume of language reflect the … of the person and the perceived … of the message

mood; importance

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when treating a potentially hostile patient, be aware of your own body language. stay calm and try to defuse the situation
assess the safety of the scene
do not assume an … posture
make good eye contact, but don’t stare
speak calmly, confidently, and slowly
never … the patient, either verbally or physically

aggressive; threaten

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cultural norms often dictate the amount of space, or …, between people when communicating
gestures, body movements, and attitude toward the patient are critically important

proximity

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as a person gets closer, a greater sense of .. must be established

trust

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… is a fundamental aspect of prehospital care

asking questions

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closed-ended questions should be used if patients cannot provide … answers and it may miss … issues

long; important

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(communication tools)

…: encouraging the patient to talk more to provide more information

facilitation

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(communication tools) …: gives the patient space and time to think and respond

silence

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(communication tools) …: restating a patient’s statmenet made to you to confirm your understanding

reflection

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(communication tools) …: being sensitive to the patient’s feelings and thoughts

empathy

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(communication tools) …: asking the patient to explain what he or she meant by an answer

clarification

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(communication tools) …: making the patient who is in denial or in a mental state of shock focus on urgent and life-critical issues

confrontation

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(communication tools) …: summing up the patient’s complaint to confirm your understandign

interpretation

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(communication tools) …: providing factual information to support a conversation

explanation

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(communication tools) ...: providing the patient with an overview of the conversation and the steps you will be taking

summary

when interviewing a patient, consider using ... to show caring and compassion. use consciously and sparingly; avoid touching the ..., ..., and ...

touch; torso; chest; face

``` interviewing techniques to avoid: providing false ... or reassurance giving ... advice asking ... or ... questions talking too much interrupting using ... questions using ... language speaking in professional jargon ```

assurance; unsolicited; leading; biased; why; authoritative

you may need to decide if having family and friends nearby will ... or ... care

help; hinder

(golden rules for communicating with patients) make and keep ... at all times provide your ... and use the patient's ... tell the patient the ... use language the patient can ...

eye contact; name; proper name; truth; understand

(golden rules for communicating with patients) be careful what you say about the patient to others be aware of your ... speak slowly, clearly, and distinctly if the patient is hard of hearing, face the patient so he or she can ... allow the patient ... to anser/respond act and speak in a ..., ... manner

body language; read your lips; time; calm; confident

(communicating with older patients) identify yourself present yourself as competent, confident, and caring do not assume that an older patient is ... or ...

senile or confused

(communicating with older patients) you may encounter ..., ..., and some ...--> do not assume this is normal behavior approach an older patient ... and ...

hostility; irritability; confusion; slowly; calmly

(communicating with older patients) watch for signs of .., ... or impaired ... or ..

confusion; anxiety; hearing; vision

(communicating with older patients) older patients often do not feel much .. so you must be especially vigilant for ... changes

pain; objective

(communicating with older patients) when possible, give patients time to pack a few ... before leaving for the hospital. locate ..., ... and ... before departure. older patients are often worried about the safety of their home, valuable items, and pets--> share these concerns with the person assuming care of the patient at the hospital

personal items; hearing aids; glasses; dentures

(communicating with children) emergency situations are frightening. Fear is most ... and .. in children. children may be frightened may be frightened by: your ..., the ..., the ... of people gathered around them

obvious; severe; uniform; ambulance; number

(communicating with children) let a child keep a favorite ..., ..., or ... if possible, have a family member or friend nearby. if practical, let the parent/guardian ... the child during evaluation and treatment

toy; doll; security blanket; hold

(communicating with children) be ...: children easily see through lies/deception tell the child ... if something will hurt respect the child's ...

honest; ahead of time; modesty

(communicating with children) speak in a ..., ... way--> use an appropriate tone and vocab maintain ... position yourself at the child's ...

professional; friendly; eye contact; level

(communicating with hearing-impaired patients) most have normal ... and are not embarrassed by their disability. position yourself so the patient can see ...

intelligence; your lips

(communicating with hearing-impaired patients) hearing aids: be careful they are not ... during an accident. They may be ... if the patient is confused. ask the family about use of a hearing aid

lost; forgotten

(communicating with hearing-impaired patients) steps to take to efficiently communicate with hearing-impaired patients:' have ... and ... available if the patient can read lips, face the patient and speak slowly and distinctly never ...

paper; pen; shout

(communicating with hearing-impaired patients) steps (cont):' listen ..., ask ... questions, and give .. answers learn some simple sign language

carefully; short; short

(communicating with visually impaired patients) ask the patient if he or she can see at all. visually impaired patients are not necessarily ... expect the patient to have normal ... ...everything you are doing as you are doing it

completely blind; intelligence; explain

(communicating with visually impaired patients) stay in ... contact witht he patient as you begin your care. if the patient can walk to the ambulance, place his/her hand on your ... transport ... such as a cane with the patient to the hospital

physical; arm; mobility aids

(communicating with visually impaired patients) guide dogs: easily identified by special ...; if possible, transport the dog with the patient as it alleviates ... for both the patient and dog. otherwise, arrange ... of the dog

harnesses; stress; care

(non English speaking patients) you must find a way to obtain a ...

medical history

(non English speaking patients) find out if the patient speaks ... use ..., ... questions point to parts of the body have a family member/friend interpret

some English; short; simple

(non English speaking patients) consider learning some ... in another language that is used in your area. pocket cards that show the pronunciation of terms are available. use a smartphone app or website to help you translate request a ... at the hospital

common phrases; translator

(communicating with other health care professionals) give an oral report to a hospital staff member who has at least ... of training

your level

(communicating with other health care professionals) oral report components: opening info: ..., chief ..., nature of ..., or ... of injury

name; complaint; illness; mechanism

(communicating with other health care professionals) oral report components (cont): detailed information: not provided during ... report any important ... that was not already provided

radio; history

(communicating with other health care professionals) oral report components (cont): patient's ... to ... given en route ... other info, such as details gathere dduring transport, known ..., and patient meds you brought with you

response; treatment; vital signs; allergies

patient care report (PCR): also known as ... legal doc records all care from ... to ...

prehospital care report; dispatch; hospital arrival

two types of PCRs: .. and ...

written; electronic

``` The PCR serves six functions: ... of care ... documentation ... ... information essential ... record ... and ... ```

continuity; legal; education; administrative; research; evaluation; continuous quality improvement

information collected on the PCR: 1. ... 2. level of ... or ... status 3. ... 4. ... 5. patient ...

chief complaint; consciousness; mental; vital signs; initial assessment; demographics

``` administrative info gathered from a PCR includes the time when: the incident was .. the EMS unit was ... the EMS unit ... at the scene the EMS unit ... the scene the EMS unit arrived at the ... patient care was ... ```

reported; notified; arrived; left; receiving facility; transferred

ePCRs allow patient info to be transmitted directly to

hospital computers

``` Elements of the narrative section of PCR: ... of events ... findings ... provided changes in patient ... ... at the scene final patient ... ... of care staff person who ... ```

time; assessment; emergency medical care; after treatment; observations; disposition; refusal; continued care

narrative section of the PCR includes significant ... and scene observations document ... not opinions avoid radio codes and use only standard abbreviations remember that the report itself is considered a ...

negatives; facts; confidential document

if you leave something out or record it incorrectly, do not try to cover it up. falsification results in poor .. and may result in ... and/or legal action

poor patient care; suspension

If you discover an error as you are writing your report, draw a single ... through the error, .. it, and write the correct info next to it. don't try to erase/cover the error

horizontal line; initial it

refusal of care is a common source of ..., so thorough documentation is crucial. document any .... and ... given. have the patient sign a ... form. Have a family member, police officer, or bystander also sign as a ... complete the PCR

lawsuits; assessment findings; emergency medical care; refusal; witness

``` depending on local reqs, special reporting situations may include: ... wounds ... bites some ... diseases suspected ... or ... abuse ... incident ```

gunshot; dog; infectious; physical; sexual; multiple-casualty

radio and telephone communications link you and your team with other members of the EMS, fire, and law enforcement communities; help the entire team work together more effectively; provide an important layer of ... and ...

safety; protection

base station: contains a ... and a ... in a ... place

transmitter; receiver; fixed

two-way radio: consists of a ... and a ...

transmitter; receiver

mobile radio: installed in a ... and is used to communicate with: .., ..., ambulances often have more than one

vehicle; dispatcher; medical control

portable radios: ... devices essential at the scene of an ... helpful when away from the ambulance to communicate with: ..., another ..., ...

hand-held; MCI; dispatch; unit; medical control

repeaters: a special ... radio receives messages and signals on ... automatically retransmits them on a ... allows two mobile/portable units that cannot reach other directly to communicate using its greater .. and ..

base station; one frequency; second frequency; power; antenna

digital signals are a part of EMS communications; ... allows electronic signals to be converted into coded, audible signals. signals can be transmitted by ... or ... to al receiver with a decoder at the hospital. data from cardiac monitors can be transmitted via Bluetooth-enabled mobile devices

radio; telephone

EMTs often communicate with receiving facilities by ...--> devices are simply low-power portable radios ... phones (...) are another option

cellular telephone; satellite phones; satphones

conversations can be easily overheard on scanners. always be careful to respect ... whenefver you use any form of EMS comm system

patient privacy

ambulances usually have an external

public address system

ems systems may use a variety of two-way radio hardware: simplex is push to ..., release to ... duplex is simultaneous ... multiplex utilizes two or more. .., which enables more than one transmission to occur simultaneously ... channels are reserved for EMS use

talk; listen; talk-listen; frequencies; MED

... systems, or 800-MHz, use the latest tech to allow greater traffic

trunking

an interoperable comm system allows all of the agencies involved to share ... info in real time

valuable

mobile data terminals inside ambulance: receive data directly from ... allow for expanded ... capabilities, such as maps

dispatch center; communication

The Federal Communications Commission (FCC) regulates all radio operations in the United States Allocates specific radio ... Licenses base stations and assign appropriate radio ... for them Establishes licensing standards and operating specifications Establishes limitations for transmitter output Monitors radio operations

frequencies; call signs;

the dispatcher receives and determines the relative importance of the ... call and assigns appropriate ...

911; EMS response units

responsibilities of dispatcher: properly ... and assign ... to each call select and alert appropriate EMS dispatch and direct EMS response unit to ... ... EMS response units with other public saftery servies until incident is over provide emergency medical instructions to caller

screen; priority; correct location; coordination;

the dispatcher should give the responding units the following info: nature and ... of injury, illness, or incident exact location of incident ... of patients responses by other public safety agencies special directions/ advisories time when units are dispatched

severity; number

emts should report to dispatcher any .. during response; emts should inform the dispatcher upon arrival

problems

the principal reason for radio comm is to facilitate comm between you and ... and the...

medical control; hospital

consulting with med control serves several purposes: notifies hospital of an ... provides an opportu nity to request ... or orders from med control advises hospital of ... situations

incoming patient; advice; special

Nine elements of patient report over radio: your unit ... and level of ... the ... and your estimated ... the patient's .. and ... patient's ... or your perception of the problem and its severity

identification; services; receiving hospital; time of arrival; age; gender; chief complaint

Nine elements of patient report over radio (contd): a brief ... of the patient's problem a brief report of physical findings a brief summary of ... given and ... a brief description of patient's ... to treatment determine if there are any questions

history; care; response; response

in most areas, medical control is provided by the physicians working at the ... many variations have developed the link to medical control is vital to maintain a high quality of care

receiving hospital

There are a number of ways to control access on ambulance-to-hospital channels: Dispatcher monitors and assigns appropriate, clear medical control ... ... medical emergency dispatch or resource coordination centers

channels; centralized

``` You may initiate communication with hospitals to advise them of an extraordinary call or situation. Other special situations: ... situations Rescues in progress ... incidents ```

Hazardous materials; Multiple-casualty

``` Keep several points in mind: The ..the notification, the better. Provide an estimate of the ...of patients. Identify any special needs. Follow your system’s plan. ```

earlier; number

Radio equipment must be serviced by properly trained and equipped personnel. The radio is your lifeline. To other... agencies (who protect you) To ...

public safety; med control

At the beginning of your shift, check the radio equipment. Radio equipment may fail during a run. The ...plan must then be followed. May include ...orders

backup; standing