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EMT > Communications and Documentation > Flashcards

Communications and Documentation Flashcards

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NREMT® EMT flashcards
1
Q

Communication

A

Transmission of information from one person to another. Can be written, verbal, or nonverbal (through body language)

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2
Q

_________ is an essential component of prehospital care and is necessary to achieve positive relationship with patients, coworkers, and others in healthcare industry.

A

Effective Communication

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3
Q

Importance of verbal communication skills

A

Enables you to gather information from the patient and bystanders.
Integral part of transferring the patient’s care to nurses and physicians at the hospital.
Effectively coordinate with a variety of responders present at the scene.

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4
Q

Documentation

A

Written or electronically recorded portion of your patient care interaction that becomes part of the patient’s permanent medical record

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5
Q

Importance of documentation

A

Demonstrates that the care delivered was appropriate, within scope of practice, and practice of the providers involved.
Communicates the patient’s story to others who may participate in the patient’s care in the future.
Adequate reporting and accurate records ensure continuity of patient care.

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6
Q

What are factors and strategies to consider during communication?

A 
Age
Body Language
Clothing
Culture
Education
Environment
Eye Contact
Facial Expression
Sex
Posture
Voice Tempo
Volume
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7
Q

Therapeutic Communication

A

Use of 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.

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8
Q

Shannon-Weaver Communication Model

A

Sender takes a thought, encodes it into a message, sends message to receiver, receiver decodes message and sends feedback to sender.

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9
Q

Ethnocentrism

A

When a person considers his or her own cultural values more important when interacting with people of a different culture

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10
Q

Cultural Imposition

A

When one person imposes his or her beliefs, values, and practices on another because he or she believes his or hers ideals are superior

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11
Q

Noise

A

Anything that dampens or obscures the true meaning of the message

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12
Q

Open-ended Questions

A

Questions in which patient needs to provide some level of detail to give an answer

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13
Q

Closed-ended Questions

A

Questions that can be answered in short or single-word responses

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14
Q

Therapeutic Communication Techniques used to help gather patient information

A 
Facilitation
Pause
Reflection
Empathy
Clarification
Confrontation
Interpretation
Explanation
Summary
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15
Q

Facilitation

A

Encourages the patient to talk more or provide more information

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16
Q

Pause

A

Do not speak. Gives patient space and time to think and respond

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17
Q

Reflection

A

Restating a patient’s statement made to you to confirm your understanding

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18
Q

Empathy

A

Be sensitive to the patient’s feelings and thoughts

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19
Q

Clarification

A

Ask the patient to explain what he or she meant by an answer

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20
Q

Confrontation

A

Make the patient who is in denial or in mental state of shock focus on urgent and life-critical issues

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21
Q

Interpretation

A

Restate the patient’s complaint to confirm your understanding

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22
Q

Explantation

A

Provide factual information to support a conversation

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23
Q

Summary

A

Provide the patient with an overview of the conversation and the steps you will take

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24
Q

What are interview techniques to avoid?

A 
Providing false hope or reassurance
Giving unsolicited advice
Ask leading or biased questions
Talk too much
Interrupt the patient
Use "why" questions
Use authoritative language
Speak in professional jargon
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25
Q

What are the 10 Golden Rules you can use to calm and reassure your patient?

A

Make and keep eye contact
Provide your name and use patient’s proper name
Tell the truth
Use of language that the patient can understand
Be careful what you say about the patient to others
Be aware of your body language
Always speak slowly, clearly, and distinctly
Face the patient so he or she can read your lips if hard of hearing
Allow time for patient to answer or respond to questions
Act and speak in a calm, confident manner

26
Q

Emotional Intelligence

A

Ability to understand and manage your own emotions and properly respond to other’s emotions

27
Q

What are the 5 attributes of emotional intelligence?

A 
Self-awareness
Self-regulation
Motivation
Empathy
Social skills
28
Q

Behavioral Change Stairway Model

A

Employ active listening
Display empathy
Build a rapport
Exert influence

29
Q

Tips to communicate with hard of hearing patients

A

Have pen and paper available
If patient can read lips and you need to remove mask have a clear barrier ready to use. Face patient and speak distinctly at a normal pace
Never shout
Listen carefully, ask short questions and give short answers
Learn simple phrases in sign language

30
Q

Mission-critical Communication

A

Any communications where disruption will result in the failure of the task at hand

31
Q

Mental Model

A

The picture an individual has in his or her head of “what’s going on” in a given situation

32
Q

Patient Care Handover

A

The transfer of pertinent patient information and the responsibility for the patient’s care

33
Q

Giving the Handover Report

A 
Initiate eye contact
Manage the environment
Ensure the ABCs
Provide a structured report (SBAR or SBAT)
Provide documentation
34
Q

SBAR

A 
Mostly used in a hospital setting but is likely to be understood by variety of healthcare providers
Situation
Background
Assessment
Recap/Rx
35
Q

SBAT

A 
Modified slightly when used in EMS
Situation
Background
Assessment
Treatment
36
Q

Receiving the Handover Report

A 
Maintain eye contact
Manage the environment
Ensure the understanding
Summarize
Gather supplementary patient documentation
37
Q

Patient Care Report

[Pre-hospital Care Report]

A

Legal document used to record all aspects of the care the patient received, from initial dispatch to arrival at the hospital.

38
Q

6 Functions of PCR

A

Transfer of information and continuity of care
Compliance and legal documentation
Administrative information
Reimbursement
Education
Data collection for quality improvement and research

39
Q

CHART

A 
Narrative format used to document care
Chief complaint or chief concern
History
Assessment
R - Treatment (Rx)
Transport
40
Q

SOAP

A 
Narrative format used to document care; simple/easy to learn
Subjective
Objective
Assessment
Plan
41
Q

What should be included in narrative section of documentation?

A 
Time of events
Assessment findings
Emergency medical provided
Changes in the patient after treatment
Observations at the scene
Final patient disposition
Refusal of care
Staff person who continued care
42
Q

Health Information Exchange (HIE)

A

Improves sharing data between EMS and other health care providers.
Allow EMS providers access to relevant health data
Avoids unnecessary duplication effort in data entry
View patient outcomes related to hospital care

43
Q

SAFR

A 
Framework that HIEs follows
Search
Alert
File
Reconcile
44
Q

Base Station

A

Any radio hardware containing a transmitter and receiver that is located in a fixed place

45
Q

Channels

A

An assigned frequency or frequencies used to carry voice and/or data communications

46
Q

Dedicated Line

A

Used for specific point-to-point contact

47
Q

VHF (Very High Frequency)

A

Mobile radios operate between 30 and 300MHz

48
Q

UHF (Ultra-high Frequency)

A

Mobile radios operate between 300MHz and 3,000MHz

49
Q

Repeater

A

Special base station radio that receives messages and signals on one frequency and then automatically retransmits them on a second frequency

50
Q

Telemetry

A

Electronic signals are converted into coded, audible signals

51
Q

Scanner

A

Radio receiver that searches or scans across several frequencies until the message is completed; process is then repeated

52
Q

Simplex

A

Push to talk, release to listen [VHF]

53
Q

Duplex

A

Simultaneous talk-listen [UHF]

54
Q

Multiplex

A

Designed to transmit audio and data signals through the use of more than one communications channel

55
Q

MED Channels

A

VHF and UHF channels reserved exclusively for EMS use

56
Q

Trunking

A

Telecommunication systems that allow a computer to maximize utilization of a group of frequencies

57
Q

Interoperable Communications System

A

Communication system that uses voice-over-Internet protocol (VoIP) technology to allow multiple agencies to communicate and transmit data

58
Q

Mobile Data Terminal (MDT)

A

Small computer terminal inside the ambulance or other vehicle that directly receives data from the dispatch center

59
Q

Federal Communication Commission (FCC)

A

Federal agency that has jurisdiction over interstate and international telephone and telegraph services and satellite communications, all of which may involve EMS activity

60
Q

Standing Orders

A

Written documents that have been signed by the EMS system’s medical director.
Outlines specific directions, permissions, and prohibitions regarding patient care.

EMT (8 decks)

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