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Emergency Medical Technician > Communications & Documentation > Flashcards

Communications & Documentation Flashcards

You may prefer our related Brainscape-certified flashcards:
Royal College: Emergency Medicine flashcards USMLE® Step 1 flashcards
1
Q

The transmission of information from on person to another

A

Communication

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2
Q

Types of communication

A
  1. Written
  2. Verbal
  3. Nonverbal
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3
Q

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

A

Documentation

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4
Q

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

A

Therapeutic communications

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5
Q

People tend to translate the messages they receive using their own ___

A

Worldview

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6
Q

Occurs when you consider your own cultural values as more important when you are interacting with people of a different culture

A

Ethnocentrism

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7
Q

When one person imposes their beliefs, values, and practices on another because they believe their ideals are superior

A

Cultural imposition

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8
Q

When you are treating a potentially hostile patient, it is important that you understand and be aware of your own ___

A

Body language

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9
Q

Steps to dealing with a hostile patient

A
  1. Assess the safety of the scene
  2. Do not assume an aggressive posture
  3. Make good eye contact, don’t stare
  4. Speak calmly, confidently, and slowly
  5. Never threaten the patient, either verbally or physically
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10
Q

Anything that dampens or obscures the true meaning of the message

A

Noise

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11
Q

Two types of questions

A
  1. Open-ended
  2. Close-ended
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12
Q

Encourage the patient to talk more or provide more information

A

Facilitation

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13
Q

Do not speak

A

Pause

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14
Q

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

A

Reflection

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15
Q

Be sensitive to the patient’s feeling and thoughts

A

Empathy

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16
Q

Ask the patient to explain what they meant by an answer

A

Clarification

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17
Q

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

A

Confrontation

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18
Q

Restate the patient’s complaint to confirm your understanding

A

Interpretation

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19
Q

Provide factual information to support a conversation

A

Explanation

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20
Q

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

A

Summary

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21
Q

10 Golden Rules to help calm and reassure your patient and provide a therapeutic rapport

A
  1. Make and keep eye contact with the patient
  2. Provide your name and use the patient’s proper name
  3. Tell the patient the truth
  4. Use language that the patient can understand
  5. Be careful what you say about the patient to others
  6. Be aware of your body language
  7. Always speak slowly, clearly, and distinctly
  8. If the patient is hard of hearing, face the person so that they can read your lips
  9. Allow time for the patient to answer or respond to questions
  10. Act and speak in a calm, confident manner
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22
Q

The ability to understand and manage your own emotions and properly respond to others’ emotions

A

Emotional intelligence

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23
Q

5 attributes of emotional intelligence

A
  1. Self-awareness
  2. Self-regulation
  3. Motivation
  4. Empathy
  5. Social skills
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24
Q

The ability to recognize your own emotions and how they affect your thoughts and behavior

A

Self-awareness

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25
Q

The ability to control impulsive emotions and behaviors and to manage emotions in positive ways

A

Self-regulation

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26
Q

The ability to motivate yourself and others in a positive direction, often deferring short-term rewards for long-term success

A

Motivation

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27
Q

The ability to understand the concerns, emotions, and needs of others by picking up on communication and social cues and clues

A

Empathy

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28
Q

The ability to develop and maintain positive rapport and relationships through effective communications

A

Social skills

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29
Q

Purposely focus your attention on the current moment, without blame and judgment for yourself or others

A

Mindfullness

30
Q

Behavioral change stairway model

A
  1. Employ active listening
  2. Display empathy
  3. Build a rapport
  4. Exert influence
31
Q

Never attribute ___ to old age

A

Altered mental status

32
Q

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

A

Mission-critical communications

33
Q

The picture individuals have in their head of “what’s going on”

A

Mental model

34
Q

For any team to work effectively together, all members must share a ___

A

Mental model

35
Q

The goal of mission-critical communications

A

An efficient, effective, and error-free transfer of the mental model

36
Q

What questions need to be answered for an individual or team to build a mental model?

A
  1. What is the focused priority for the patient?
  2. What is the history of prior care?
  3. What is the patient’s current state?
  4. What are the patient’s immediate needs?
37
Q

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

A

Patient care handover or handoff

38
Q

Giving the handover report

A
  1. Initiate eye contact
  2. Manage the environment
  3. Ensure the ABCs
  4. Provide a structured report
  5. Provide documentation
39
Q

SBAR

A

Situation
Background
Assessment
Recap/Rx

40
Q

SBAT

A

Situation
Background
Assessment
Treatment

41
Q

Receiving the handover report

A
  1. Maintain eye contact
  2. Manage the environment
  3. Ensure understanding
  4. Summarize
  5. Gather supplementary patient documentation
42
Q

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

A

Patient care report

43
Q

Another term for the patient care report

A

Pre-hospital care report

44
Q

Usually you will finish the PCR after ___

A

You have transferred care of the patient to an ED staff member

45
Q

Two types of PCRs

A

Written
Electronic (ePCRs)

46
Q

The minimum data set for NEMSIS

A

Both narrative components and check boxes

47
Q

PCR functions

A
  1. Transfer of info and continuity of care
  2. Compliance and legal documentation
  3. Admin info
  4. Reimbursement
  5. Education
  6. Data collection for quality improvement and research
48
Q

EMS documentation uses ___ time

A

Military

49
Q

Two most common narrative formats for PCRs used in health care

A

CHART
SOAP

50
Q

CHART

A

Chief complaint/concern
History
Assessments
(Rx) treatments
Transport

51
Q

SOAP

A

Subjective
Objective
Assessment
Plan

52
Q

This narrative format method’s strength is that it groups the care and treatment into smaller, logical sections, which makes it easier to locate specific assessments or care without reading the entire report

A

CHART

53
Q

Weakness of CHART

A

Somewhat difficult to learn

54
Q

For location in CHART ___

A

Be specific with the type of location, don’t just say scene

55
Q

Chief complaint vs chief concern

A

Complaint is what they are complaining of, but concern is the underlying problem that you are concerned about as an EMT

56
Q

PCRs should include this information

A
  1. Time of events
  2. Assessment findings
  3. Emergency medical care provided
  4. Changes in the patient after treatment
  5. Observations at the scene
  6. Final patient disposition
  7. Refusal of care
  8. Staff person who continued care
57
Q

Medicare and Medicaid payers will reimburse for ambulance transport only in the services are documented as being ___

A

Medically necessary

58
Q

Means it would have been unsafe or impossible to transport the patient by any other means

A

Medically necessary

59
Q

A system that allows EMS providers to access relevant health data, avoid unnecessary duplication of effort in data entry, and view patient outcomes related to hospital care

A

Health information exchange

60
Q

HIE

A

Health information exchange

61
Q

Most HIEs follow the ___ framework to improve patient care by giving health care providers rapid and universal access to accurate patient medical information

A

SAFR

62
Q

SAFR

A

Search
Alert
File
Reconcile

63
Q

MCI

A

Mass casualty incident

64
Q

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

A

Base station

65
Q

As assigned frequency used to carry voice and/or data communications

A

Channel

66
Q

Used for specific point-to-point contact

A

Dedicated line

67
Q

Dedicated line is also know as a ___

A

Hotline

68
Q

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

A

Repeater

69
Q

Electronic signals are converted into coded, audible signals

A

Telemetry

70
Q

A radio receiver that searches or scans across several frequencies, stops whenever it receives a radio broadcast on that frequency, and continues once the message is complete

A

Scanner

Emergency Medical Technician (100 decks)

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