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EMT Summer 2020 > Chapter 4- Communications and Documentation > Flashcards

Chapter 4- Communications and Documentation Flashcards

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1
Q

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

A

written; electronically

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2
Q

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

A

transfer; health departments; law enforcement

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3
Q

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

A

EMS; fire dept; law enforcement

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4
Q

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

A

how they feel; positive

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5
Q 
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
A

thought; message; receiver; decodes; feedback

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6
Q

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

A

ethnocentrism

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7
Q

forcing your values onto others: …

A

cultural imposition

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8
Q

…: anything that dampens or obscures true meaning of message

A

noise

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9
Q

… questions require some level of detail in the response

A

open-ended

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10
Q

…can be answered in very short responses

A

Closed-ended questions

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11
Q

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

A

mood; importance

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12
Q

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

A

aggressive; threaten

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13
Q

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

A

proximity

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14
Q

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

A

trust

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15
Q

… is a fundamental aspect of prehospital care

A

asking questions

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16
Q

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

A

long; important

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17
Q

(communication tools)

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

A

facilitation

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18
Q

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

A

silence

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19
Q

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

A

reflection

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20
Q

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

A

empathy

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21
Q

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

A

clarification

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22
Q

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

A

confrontation

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23
Q

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

A

interpretation

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24
Q

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

A

explanation

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25
Q

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

A

summary

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26
Q

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

A

touch; torso; chest; face

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27
Q 
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
A

assurance; unsolicited; leading; biased; why; authoritative

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28
Q

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

A

help; hinder

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29
Q

(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 …

A

eye contact; name; proper name; truth; understand

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30
Q

(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

A

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

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31
Q

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

A

senile or confused

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32
Q

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

A

hostility; irritability; confusion; slowly; calmly

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33
Q

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

A

confusion; anxiety; hearing; vision

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34
Q

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

A

pain; objective

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35
Q

(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

A

personal items; hearing aids; glasses; dentures

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36
Q

(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

A

obvious; severe; uniform; ambulance; number

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37
Q

(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

A

toy; doll; security blanket; hold

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38
Q

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

A

honest; ahead of time; modesty

39
Q

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

A

professional; friendly; eye contact; level

40
Q

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

A

intelligence; your lips

41
Q

(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

A

lost; forgotten

42
Q

(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 …

A

paper; pen; shout

43
Q

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

A

carefully; short; short

44
Q

(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

A

completely blind; intelligence; explain

45
Q

(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

A

physical; arm; mobility aids

46
Q

(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

A

harnesses; stress; care

47
Q

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

A

medical history

48
Q

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

A

some English; short; simple

49
Q

(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

A

common phrases; translator

50
Q

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

A

your level

51
Q

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

A

name; complaint; illness; mechanism

52
Q

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

A

radio; history

53
Q

(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

A

response; treatment; vital signs; allergies

54
Q

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

A

prehospital care report; dispatch; hospital arrival

55
Q

two types of PCRs: .. and …

A

written; electronic

56
Q 
The PCR serves six functions: 
... of care
... documentation 
... 
... information 
essential ... record 
... and ...
A

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

57
Q

information collected on the PCR:

  1. …
  2. level of … or … status
  3. …
  4. …
  5. patient …
A

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

58
Q 
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 ...
A

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

59
Q

ePCRs allow patient info to be transmitted directly to

A

hospital computers

60
Q 
Elements of the narrative section of PCR: 
... of events
... findings
... provided
changes in patient ... 
... at the scene
final patient ... 
... of care
staff person who ...
A

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

61
Q

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 …

A

negatives; facts; confidential document

62
Q

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

A

poor patient care; suspension

63
Q

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

A

horizontal line; initial it

64
Q

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

A

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

65
Q 
depending on local reqs, special reporting situations may include: 
... wounds
... bites
some ... diseases
suspected ... or ... abuse
... incident
A

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

66
Q

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 …

A

safety; protection

67
Q

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

A

transmitter; receiver; fixed

68
Q

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

A

transmitter; receiver

69
Q

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

A

vehicle; dispatcher; medical control

70
Q

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

A

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

71
Q

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 ..

A

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

72
Q

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

A

radio; telephone

73
Q

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

A

cellular telephone; satellite phones; satphones

74
Q

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

A

patient privacy

75
Q

ambulances usually have an external

A

public address system

76
Q

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

A

talk; listen; talk-listen; frequencies; MED

77
Q

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

A

trunking

78
Q

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

A

valuable

79
Q

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

A

dispatch center; communication

80
Q

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

A

frequencies; call signs;

81
Q

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

A

911; EMS response units

82
Q

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

A

screen; priority; correct location; coordination;

83
Q

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

A

severity; number

84
Q

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

A

problems

85
Q

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

A

medical control; hospital

86
Q

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

A

incoming patient; advice; special

87
Q

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

A

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

88
Q

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

A

history; care; response; response

89
Q

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

A

receiving hospital

90
Q

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

A

channels; centralized

91
Q 
You may initiate communication with hospitals to advise them of an extraordinary call or situation.
Other special situations:
... situations
Rescues in progress 
... incidents
A

Hazardous materials; Multiple-casualty

92
Q 
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.
A

earlier; number

93
Q

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

A

public safety; med control

94
Q

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

A

backup; standing

EMT Summer 2020 (13 decks)

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