Communications and Documentation Flashcards
Communication
Transmission of information from one person to another. Can be written, verbal, or nonverbal (through body language)
_________ is an essential component of prehospital care and is necessary to achieve positive relationship with patients, coworkers, and others in healthcare industry.
Effective Communication
Importance of verbal communication skills
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.
Documentation
Written or electronically recorded portion of your patient care interaction that becomes part of the patient’s permanent medical record
Importance of documentation
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.
What are factors and strategies to consider during communication?
Age Body Language Clothing Culture Education Environment Eye Contact Facial Expression Sex Posture Voice Tempo Volume
Therapeutic Communication
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.
Shannon-Weaver Communication Model
Sender takes a thought, encodes it into a message, sends message to receiver, receiver decodes message and sends feedback to sender.
Ethnocentrism
When a person considers his or her own cultural values 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 believes his or hers ideals are superior
Noise
Anything that dampens or obscures the true meaning of the message
Open-ended Questions
Questions in which patient needs to provide some level of detail to give an answer
Closed-ended Questions
Questions that can be answered in short or single-word responses
Therapeutic Communication Techniques used to help gather patient information
Facilitation Pause Reflection Empathy Clarification Confrontation Interpretation Explanation Summary
Facilitation
Encourages the patient to talk more or provide more information
Pause
Do not speak. Gives patient space and time to think and respond
Reflection
Restating a patient’s statement made to you to confirm your understanding
Empathy
Be sensitive to the patient’s feelings and thoughts
Clarification
Ask the patient to explain what he or she meant by an answer
Confrontation
Make the patient who is in denial or in mental state of shock focus on urgent and life-critical issues
Interpretation
Restate the patient’s complaint to confirm your understanding
Explantation
Provide factual information to support a conversation
Summary
Provide the patient with an overview of the conversation and the steps you will take
What are interview techniques to avoid?
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
What are the 10 Golden Rules you can use to calm and reassure your patient?
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
Emotional Intelligence
Ability to understand and manage your own emotions and properly respond to other’s emotions
What are the 5 attributes of emotional intelligence?
Self-awareness Self-regulation Motivation Empathy Social skills
Behavioral Change Stairway Model
Employ active listening
Display empathy
Build a rapport
Exert influence
Tips to communicate with hard of hearing patients
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
Mission-critical Communication
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
Patient Care Handover
The transfer of pertinent patient information and the responsibility for the patient’s care
Giving the Handover Report
Initiate eye contact Manage the environment Ensure the ABCs Provide a structured report (SBAR or SBAT) Provide documentation
SBAR
Mostly used in a hospital setting but is likely to be understood by variety of healthcare providers Situation Background Assessment Recap/Rx
SBAT
Modified slightly when used in EMS Situation Background Assessment Treatment
Receiving the Handover Report
Maintain eye contact Manage the environment Ensure the understanding Summarize Gather supplementary patient documentation
Patient Care Report
[Pre-hospital Care Report]
Legal document used to record all aspects of the care the patient received, from initial dispatch to arrival at the hospital.
6 Functions of PCR
Transfer of information and continuity of care
Compliance and legal documentation
Administrative information
Reimbursement
Education
Data collection for quality improvement and research
CHART
Narrative format used to document care Chief complaint or chief concern History Assessment R - Treatment (Rx) Transport
SOAP
Narrative format used to document care; simple/easy to learn Subjective Objective Assessment Plan
What should be included in narrative section of documentation?
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
Health Information Exchange (HIE)
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
SAFR
Framework that HIEs follows Search Alert File Reconcile
Base Station
Any radio hardware containing a transmitter and receiver that is located in a fixed place
Channels
An assigned frequency or frequencies used to carry voice and/or data communications
Dedicated Line
Used for specific point-to-point contact
VHF (Very High Frequency)
Mobile radios operate between 30 and 300MHz
UHF (Ultra-high Frequency)
Mobile radios operate between 300MHz and 3,000MHz
Repeater
Special base station radio that receives messages and signals on one frequency and then automatically retransmits them on a second frequency
Telemetry
Electronic signals are converted into coded, audible signals
Scanner
Radio receiver that searches or scans across several frequencies until the message is completed; process is then repeated
Simplex
Push to talk, release to listen [VHF]
Duplex
Simultaneous talk-listen [UHF]
Multiplex
Designed to transmit audio and data signals through the use of more than one communications channel
MED Channels
VHF and UHF channels reserved exclusively for EMS use
Trunking
Telecommunication systems that allow a computer to maximize utilization of a group of frequencies
Interoperable Communications System
Communication system that uses voice-over-Internet protocol (VoIP) technology to allow multiple agencies to communicate and transmit data
Mobile Data Terminal (MDT)
Small computer terminal inside the ambulance or other vehicle that directly receives data from the dispatch center
Federal Communication Commission (FCC)
Federal agency that has jurisdiction over interstate and international telephone and telegraph services and satellite communications, all of which may involve EMS activity
Standing Orders
Written documents that have been signed by the EMS system’s medical director.
Outlines specific directions, permissions, and prohibitions regarding patient care.
