Chaptwr 4 Flashcards
Communication
The transmission of information from one person to another—whether it is written, verbal, or nonverbal.
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.
Shannon-Weaver communication model
Mathematical theory of communication
Therapeutic communication
Uses versions 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.
Ethnocentrism
When a person considers his or her own cultural values as more important when interacting with people of a different culture.
Cultural imposition
When one person imposes his or her beliefs, values, and practices on another because he or she believe his or her ideals are superior.
Noise
Anything that dampens or obscures the true meaning of the messages.
Rapport
A trusting relationship that you build with your patient.
Mission-critical communications
Any communications where disruption will result in the failure of the task at hand.
Mental model
The picture an individual has in his or her head of “what’s going on” in a given situation.
Handover
The transfer of pertinent patient information and the responsibility for the patient’s care.
SBAR
Situation
Background
Assessment
Recap/Rx
SBAT
Situation
Background
Assessment
Treatment
Patient Care Report (PCR)
The legal document used to record all aspects of the care your patient received, from initial dispatch to arrival at the hospital.
6 functions of the PCR
- Transfer of information and continuity of care
- Compliance and legal documentation
- Administrative information
- Reimbursement
- Education
- Data collection for quality improvement and research
CHART
Cheif complaint or Cheif concern History Assessments Rx/Treatments Transport
SOAP
Subjective
Objective
Assessment
Plan
Medical necessity
Transportation that takes place when it would have been unsafe or impossible to transport the patient by any other means.
Health Information Exchange (HIE)
A system that allows EMS providers to access relevant health data (eg, past medical problems, medications, allergies, end-of-life decisions), avoid unnecessary duplication of effort in data entry, and view patient outcomes related to hospital care.
SAFR framework
Search
Alert
File
Reconcile
