*(Chapter 5) Communication And Documentation Flashcards
What is empathy?
The ability to see things from the patient’s perspective.
What does E-PCR stand for?
Electronic Patient Care Report.
What is the role of the Federal Communications Commission (FCC)?
Regulates all radio operations in the U.S.
What is telemedicine?
Delivery of healthcare services via real-time telecommunication technologies.
What is therapeutic communication?
Techniques prioritizing the physical, mental, and emotional well-being of patients.
What are the primary forms of EMS communication?
Dispatch, emergency responders, and medical direction.
What are portable radios used for?
Handheld communication with limited range, often supported by repeaters.
How do mobile radios differ from portable radios?
They are vehicle-mounted and have a greater range.
What is a base station?
A fixed transmitter/receiver in contact with all radio system components.
What is the purpose of a repeater?
To amplify low-power transmissions and improve range.
What are MDCs (Mobile Data Computers)?
Devices that relay digital information, reducing radio traffic.
What are the advantages and disadvantages of cellphones in EMS?
Advantages: Easy, clear audio, inexpensive. Disadvantages: Unreliable during peak demand or mass casualty incidents.
What are key rules for radio communication?
- Confirm receipt of dispatch information. 2. Notify dispatch at all phases of the call. 3. Use correct radio/frequency and clear, concise language.
What is included in a report to medical direction?
Patient’s age, chief complaint, vitals, history, treatments, and requests for additional interventions.
What are the main purposes of a Patient Care Report (PCR)?
- Ensure continuity of care. 2. Serve as a legal document. 3. Support billing and quality improvement.
What must be included in the minimum data set?
Accurate times for dispatch, arrival, and transfer of care.
What are the steps for transferring care?
- Provide a verbal report. 2. Submit a written PCR. 3. Obtain a signature from the accepting provider.
What are key components of interpersonal communication?
- Encoding and decoding messages. 2. Awareness of tone and non-verbal cues. 3. Building rapport through honesty and respect.
What should be avoided during communication?
- False promises or biased language. 2. Advice beyond your scope. 3. Overusing medical jargon.
What are principles of therapeutic communication?
- Show compassion, empathy, and competence. 2. Use open-ended questions. 3. Avoid judgmental statements.
What is telemedicine used for in EMS?
Real-time communication between responders and physicians for medical direction.
What is Mobile Integrated Healthcare (MIH)?
A collaboration between EMS and healthcare facilities for integrated care.
What must be included in a verbal transfer of care?
All relevant patient information, including updates since radio reports.
What is required for written transfer of care?
A patient care report (PCR) must accompany the patient.
What signature is required during transfer of care?
Obtain a signature from the accepting provider verifying transfer of care.
What does effective communication involve?
The sender “encodes” the message; the receiver “decodes” it.
What factors influence communication?
Non-verbal cues, attitude, and tone significantly impact effectiveness.
How can you establish rapport with a patient?
Introduce yourself, address the patient by name, be honest, and respect cultural differences.
What should you avoid in communication?
Avoid false promises, biased language, confrontational behavior, and overusing medical jargon.
What are challenging communication scenarios?
Patients with disabilities, those under the influence of drugs/alcohol, and pediatric patients.
What is therapeutic communication?
A style of communication showing compassion, empathy, and commitment to the patient’s well-being.
How can you effectively question patients?
Use open-ended questions for information and closed questions for specifics; avoid judgmental language.
What is telemedicine?
Real-time communication with physicians for medical direction.
What is Mobile Integrated Healthcare (MIH)?
Coordinated care among EMS and healthcare providers to reduce hospital visits.
What is the purpose of the PCR?
Continuity of care, legal documentation, billing, and quality improvement.
What are the key rules for documentation?
Document only what you did; if it’s not documented, it wasn’t done; ensure accurate timing.
What content must a PCR include?
Patient demographics, assessment findings, treatments, and administrative details.
What are the common documentation formats?
FACT (Factual, Accurate, Complete, Timely), SOAP (Subjective, Objective, Assessment, Plan), CHART (Chief complaint, History, Assessment, Rx, Transport).
What should you avoid in documentation?
Spelling errors, unapproved abbreviations, and falsifications.
What are errors of omission?
Leaving out critical details from the report.
What are errors of commission?
Including incorrect or misleading information in the report.
What must you document for patient refusals?
Patient capacity, treatments offered/refused, risks explained, and witness signatures.
What steps should you take for patient refusals?
Call medical direction for advice and recommend the patient call EMS again if they change their mind.
What are possible special reporting situations?
Death, mass casualty incidents, abuse, suspected crimes, animal bites, and disease outbreaks.
What is abandonment in EMS?
Failing to give a verbal transfer of care to an equal or higher authority.
Why is cultural competence important?
It helps tailor communication to diverse patient needs and ensures effective care.
