Communication and Documentation

Question 1

What are the communication devices used in EMS Systems

Answer 1

• EMS uses various communication systems:
– Radios
– One-way pagers
– Cell phones
– Traditional telephones (landlines)

Question 2

What are the components of a radio system

Answer 2

• EMS radio systems consist of: 
– Base station
– Mobile radios
– Portable radios
– Repeaters
– Microwave transmissions 
– Digital radio signals

Question 3

Who regulates radio communicaitons

Answer 3

• Regulated by the Federal Communications Commission (FCC)
– Assign and license designated radio frequencies
– Establish rules regarding appropriate language
– Monitor radio traffic

Question 4

What are the principles of radio communication

Answer 4

• Radio on and volume adjusted properly
• Reduce background noise
• Ensure frequency is clear before starting
• Press PTT (press to talk) button on radio; wait 1 second before speaking
• Lips about 2–3 inches from microphone
• Use unit names or numbers
• Call unit’s attention first; wait for “go ahead”
• Unit may say “stand by” until ready
• Speak slowly and clearly
• Keep it brief
• Use plain English, avoid codes
• Avoid unnecessary words (“be advised” or “please”)
• If number might be unclear, say number and repeat individual digits
• Never use patient’s name over radio
• Never use profanities or slander
• Use objective, impartial statements
• Use “we” instead of “I”
• “Affirmative” and “negative” preferred over
“yes” and “no”
• Give assessment information about patient; avoid offering diagnosis
• After transmitting, say “Over”
• Avoid slang or unauthorized abbreviations
• Use EMS frequencies for authorized EMS communication only

Question 5

Other Radio Procedures

Answer 5

• If two units transmit simultaneously, only
one will be heard by listeners
• Dispatch often confirms receipt of transmission by repeating part of it back
• Dispatch may end transmission with time for documentation
• Carry portable radio whenever you leave unit
• Radios need proper care and maintenance

Question 6

Medical Radio Reports

Answer 6

• Report must be given to destination hospital so it can prepare for arrival
– Usually done by radio
– Structured to present only most important information
– Speak clearly and slowly

Question 7

What are the parts of the Medical Report

Answer 7

1. Unit identification and level of provider
2. Estimated time of arrival (ETA)
3. Patient’s age and sex
4. Chief complaint
5. Brief, pertinent history of present illness/injury
6. Major past illnesses
7. Mental status
8. Baseline vital signs
9. Pertinent findings of physical exam
10. Emergency care given
11. Response to medical care
12. Medical direction if required, or if questions

Question 8

Things to think about when Communicating With Medical Control

Answer 8

• Give information clearly and accurately
• After receiving order or denial for medication or procedure, repeat back word for word
• If order unclear, ask physician to repeat
• If order seems inappropriate, question physician

Question 9

How do you deliver a Detailed Verbal Report

Answer 9

• Given upon arrival at destination
• Introduce patient by name
• Give complete and detailed report
• Elements of report
– Chief complaint
– History of present illness/injury
– Assessment findings, including pertinent negatives
– Treatment given and response
– Complete vital signs

Question 10

Elements of Team Communication

Answer 10

• EMT must communicate with others involved in patient’s care
– First responders
– Advanced EMTs, paramedics 
– Home healthcare aides, family
• Speak candidly and respectfully 
• Collect information about patient

Question 11

Therapeutic Communication

Answer 11

• Communication techniques learned by experience
• May be more difficult with those in crisis
• Everyone can improve communication skills

Question 12

Communication Techniques

Answer 12

• Use eye contact
• Shows interest, comfort, and respect
• Be aware of position and body language
• Face patient at eye level, arms down
• Use appropriate language
• Ensure patient understands
• Be honest
• Dishonesty ruins confidence and rapport
• Use patient’s proper name
• Sign of respect, especially with older patients
• Listen
• Important to establish trust

Question 13

Communication Techniques - Special Considerations

Answer 13

• Special considerations
• Always be compassionate and respectful
• Mentally disabled
• Visual or hearing impaired
• Language barriers
• Pediatric patients
• Come down to their level
• Be truthful

Question 14

What is the function of the PCR

Answer 14

• Patient care record
– Documents findings and treatment
– Conveys picture of scene
– Entered into patient’s permanent medical record

• Legal document
– Can be subpoenaed and used as evidence – May help patient win a case
– May be used against you in case of negligence

• Administrative
– Demographic information
– Insurance information
– Billing address

• Education and research 
– Clinical research
– Statistics
– Continuing education
– Tracking EMT’s personal experience

• Quality improvement
– Routine call review
– Ensures compliance to standards
– Can reveal providers deserving special recognition
– Can reveal opportunities for improvement

Question 15

Elements of PCR

Answer 15

Run data
• Agency name, date, times, call number, unit personnel, certification levels, other information mandated by service
• Use official time given by dispatch so all times in report match

• Patient information
– Name, address, phone number
 – Gender, age, date of birth
– Weight
– Race and/or ethnicity
– Billing and insurance information

• Information gathered during call
• General impression of patient
• Narrative summary of call
• Patient history and treatment as required by service
• Transport information

Question 16

Elements of Narrative Summary

Answer 16

• Objective information
– Observable, measurable, verifiable
• Subjective information
– Subject to interpretation or opinion (often reported by patient)
• Chief complaint
– Primary complaint, as stated by patient
– Best recorded as a direct quote
• Pertinent negatives
– Important negative findings
• Plain English and approved abbreviations
– Avoid codes and unofficial abbreviations
• Legible; correct spelling and grammar
– Information must be read easily and accurately
– PCR is a reflection of your care
• Appropriate medical terminology
• If it happened, record it

Your report should paint a picture of you patient & his condition, accurately describing your contact throughout the call

Question 17

Confidentiality of PCR

Answer 17

Confidentiality
– Covered by HIPAA
– Accountability and security

Question 18

Refusals and the PCR

Answer 18

• Refusals
– High liability
– Document all details in a “refusal of care” form

Question 19

What are examples of Documentation Issues

Answer 19

• Falsification
– Covering up errors
– Recording something you forgot to do
• Correction of errors
– Mistakes in documentation 
– Additions

Question 20

• You respond to a call for an unconscious male. Upon arrival the patient is awake, alert, and walking away. He states he was just sleeping, and does not need or want treatment or transport.

• Is this a patient?
• Is a complete assessment and physical exam needed?
• How will you document this call?
• Should you obtain a formal patient refusal?

Answer 20

My answer
• Yes - there is a reason he is unconscious - he may just be embarrassed
• Yes - you always start from the beginning and do a complete assessment
• Document all elements
• obtain a refusal

Question 21

Special Situations Reports

Answer 21

• Multiple casualty incidents
– Logistical problem for EMS
– Many patients
– Care and evaluation by several providers at different times and locations

Question 22

Special Situation Reports

Answer 22

• Provider exposures
• Provider injuries
• Hazardous or unsafe scenes
• Referrals to social service agencies
• Reports of abuse

Question 23

Chapter Review

Answer 23

• Radio report should include:
 unit ID and provider level; ETA; 
patient’s age and sex; 
chief complaint; 
pertinent HPI;
major past illnesses; 
mental status; 
baseline vital signs; 
physical exam findings; 
emergency care given and response; 
request to contact medical direction.

Question 24

Chapter Review

Answer 24

• PCR should include patient’s name, address, date of birth, age, and sex; billing and insurance information; nature of call; MOI; location patient was found; treatment given before EMT arrival.

Question 25

Chapter Review

Answer 25

• PCR may be a legal document in a court
proceeding.
• Data from PCRs may help determine future treatments, trends, research, and quality improvement.
• Your report should “paint a picture” of your patient and their condition, accurately describing your contact with the patient throughout the call.

Question 26

Remember

Answer 26

• Emergency medical communication comes in many forms and is essential to team-based patient care.
• The medical radio report is structured to present pertinent facts about the patient without providing more detail than necessary.
• A proper verbal report will include the chief complaint, any history that was not given previously, additional treatment given, and additional vital signs taken en route.
• Interpersonal communication is often challenging in EMS. Adopting best practices can improve communication capabilities significantly.
• Confidentiality, patient refusals, and falsification of records are all-important legal concepts that an EMT must consider when documenting a call.

Question 27

Consider • How can you improve your interpersonal communication with patients and team members?

Answer 27

My answer:

Remember to talk to the pt and give them the respect and information you would want

Question 28

• What is “objective” and “subjective” information in the narrative portion of the PCR?

Answer 28

My answer
• Objective is measured or clearly observable information
• Subjective

Question 29

Critical Thinking -
• Organize this random information, and present a radio report to the hospital.
– Chest pain radiating to shoulder
– 56 years old
– Oxygen applied at 15 L/minute via nonrebreather
– Alert and oriented
– Female
– Came on 20 minutes ago while mowing lawn
– History of high blood pressure and diabetes
– Pulse 86, respirations 22, skin cool and moist, blood pressure 110/66, SpO2 96%
– Oxygen relieved pain slightly
– Denies difficulty breathing
– Requesting orders from medical direction
– You are on Community BLS Ambulance 4
– Lung sounds equal on both sides – Placed in a position of comfort
– ETA 20 minutes
• Write a narrative report for the same call. Will you use different information?

Answer 29

1. Unit identification and level of provider
2. Estimated time of arrival (ETA)
3. Patient’s age and sex
4. Chief complaint
5. Brief, pertinent history of present illness/injury
6. Major past illnesses
7. Mental status
8. Baseline vital signs
9. Pertinent findings of physical exam
10. Emergency care given
11. Response to medical care
12. Medical direction if required, or if questions

–You are on Community BLS Ambulance 4
– ETA 20 minutes
– 56 years old
– Female
– Chest pain radiating to shoulder
– History of high blood pressure and diabetes
– Alert and oriented
– Pulse 86, respirations 22, skin cool and moist, blood pressure 110/66, SpO2 96%
– Lung sounds equal on both sides
– Oxygen applied at 15 L/minute via nonrebreather
– Oxygen relieved pain slightly
– Denies difficulty breathing
– Requesting orders from medical direction

Question 30

base station

Answer 30

a two way radio at a fixed site such as a hospital or dispatch center

Question 31

mobile radio

Answer 31

a two way radio that is used or affixed in a vehicle

Question 32

watt

Answer 32

the unit of measurement of the output power of a radio

Question 33

portable radio

Answer 33

a handheld two way radio

Question 34

repeater

Answer 34

a device that picks up signals from lower-power radio units, such as mobile and portable radios, and retransmits them at a higher power. It allows low-power radio signals to be transmitted over longer distances

Question 35

cell phone

Answer 35

a phone that transmits through the air instead of over wires so that the phone can be transported and used over a wide area

Question 36

drop report (or transfer report)

Answer 36

an abbreviated form of the PCR that an EMS crew can leave at the hospital when there is not enough time to complete the PCR before leaving

Question 37

NHSTA Minimum Data Set

Answer 37

Patient Information
This information is gathered at the time of the EMT;\'s initial contact with a patient upon arrival at the scene, following all interventions, and upon arrival at the medical facility:
• Chief Complaint
• Level of responsiveness (AVPU) - mental status
• Systolic blood pressure >yrs old
• Skin Perfusion (cap refill <6yrs)
• Skin color and temp
• Pulse
• Respiratory Rate and effort

Administrative Information
• Time of Incident
• Time uit notified
• Time of arrival of patient
• Time unit left scene
• Time of arrival at destination
• Time of transfer of care

Question 38

Key Decisions

Answer 38

• What radio procedure should I follow at this (or any) stag of the call
• What elements should I include in the medical radio report
• What information about this pt must I include in the care report
• What steps must I take to avoid legal issues during communication and documentation for this call?

Question 39

TEST REVIEW

know base station and repeaters - what they do

Answer 39

.

Question 40

what inside an ambulance, vs stations, vs in a house

Answer 40

ambulance - mobile radio
house - 2 way - 
radios - recorded lines all the time
repeaters - picks up signal and amplifies it sends it on
cell phone -

page 396 - picture know the parts
page 397 - principles of using the radio

Question 41

trauma alert -

Answer 41

have to call it - drs on call come in
cat scan is cleared
technical trauma alert - but is not critical - call the hospital and let them know

Question 42

Radio Report

Answer 42

.

Question 43

CHART and SOAP method

Answer 43

idiograms for writing a report

Question 44

refusal forms

Answer 44

.

Question 45

.

Answer 45

Writing a PCR
Why do we have a Patient Care Report?

It was developed by a committee of EMS providers and administrators assembled from across the state for the purpose of establishing a statewide EMS data system
So…what is it?

The PCR is:
a medical record

• the form becomes part of the patient record and allows for continuity of care
• a legal document
• it’s a way for the prehospital care providers to prove what treatment he/she gave
• a standardized record

When to use a PCR

A PCR should be filled out for every call, including emergencies, fire standbys, mutual aid standbys, etc.

If you were dispatched for a call a PCR needs to be filled out even if you were cancelled

Writing a PCR – the Narrative

CHART
Chief Complaint
History
Allergies
Rx-Treatment
Transport
Chief Complaint

This is where the patient’s chief complaint should be noted. Remember that chief complaint and reason for dispatch are not always the same. Example: MVC is a reason for dispatch but should not be the chief complaint. The complaint should be phrased in such a way as “arrived on scene to find this ____ yo male complaining of ____ or Arrived to find this ___ yo femalewith cieif complaint of ___.

You can use patient statements in the chief complaint just as you would under the subjective heading of SOAP notes. Remember that anything the patient states should be placed in quotation marks..

History

This mainly deals with the history of the present illness or injury(HPI). This portion of the Report should immediately follow the chief complaint. HPI should include such information as time of onset, duration of signs & symptoms (S/S), anything that provokes or relieves the S/S, prior onset of S/S etc. The history should also support any diagnosis that has been made. Does the patient have a Hx of hypertension, MI, Diabetes, etc.

History does not need to include things that have no relevance as in the patient having an appendectomy 12 years ago.

Assessment

What was the result of your exam of patient during your assessment. Neurological status, Level of Consciousness (LOC), pupils, movement of extremities, etc. This should include patients communication ability, Skin condition, pedal edema, lung fields, etc. DCAP-BTLS, Head to toe exam. If you have the patient for more than 20 minutes there should be more than one assessment on the patient!

Rx- Treatment

This is where you document your treatment and response of the patient to your treatment of the patient. All treatment should be documented both successful and unsuccessful. If you use check boxes to document part of the treatment make sure you reference it in your comments. Many times reviewers will not look at the check boxes unless there is a reference to it in the comments. Please note significant changes in the patient’s condition after treatment are rendered. Example: “pain decreased to 5/10 from 7/10 after NTG X 2 given.” Be meticulous about documenting airway procedures and always document patency of airways prior to turning over patient care to others.

Transport

This is where any other changes would be placed in the reun report. If anything unusual occurred during the transport of the patient. If for some reason there was an alteration in protocol for some reason this should be documented thoroughly. You should also report whom the care of the patient was turned over to being as specific as possible.

Remember, If you didn’t write it…..

You didn’t do it!

What to write on a PCR

Anything that you did for the patient
Anything you found during the assessment
How you found the patient
Where you left the patient
Anything unusual with the call
Who started care before you got there
If you did it, you should write it.
What not to write on a PCR
Any foul or objectionable language
Any 10 Codes or other radio codes
Anything that could be considered libel
for example: "He was drunk"
How do I word objectionable phrases into stuff I can use

“He was drunk” = “Patient had an odor of intoxicating substance on breath”

How do you know that the patient was drunk? Could have had an AMS due to a head injury, a diabetic emergency, a stroke, etc.

If the patient tells you he was drinking, document factually: “Patient admits to drinking 2 40 ounce bottles of beer.”

How do I word objectionable phrases into stuff I can use

“He was high” = “Patient unable to stand on his own without staggering and has auditory and visual hallucinations”.

How do you know that the patient was high? Could have had an AMS due to a head injury, a diabetic emergency, a stroke, etc.

If the patient tells you he was drinking, document factually: “Patient admits to using illicit substances”.

Grammar and Spelling

Make sure that your grammar and spelling are correct. It will make a big difference to people reading it, including lawyers!!

If you’re not careful with your spelling, how careful were you with your patient care.

Your PCR is full of fun-filled words. Remember, most of what you need to write is already on your PCR.

Going to court

Better be sure that your documentation was well-written

Most EMS personnel don’t go to court until 4-5 years after the call was done - Good documentation is important!!!

UOA - upon our arrival