Communications & Documentation Flashcards
The transmission of information from on person to another
Communication
Types of communication
- Written
- Verbal
- Nonverbal
Written or electronically recorded portion of your patient care interaction that becomes part of the patient’s permanent medical record
Documentation
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
Therapeutic communications
People tend to translate the messages they receive using their own ___
Worldview
Occurs when you consider your own cultural values as more important when you are interacting with people of a different culture
Ethnocentrism
When one person imposes their beliefs, values, and practices on another because they believe their ideals are superior
Cultural imposition
When you are treating a potentially hostile patient, it is important that you understand and be aware of your own ___
Body language
Steps to dealing with a hostile patient
- Assess the safety of the scene
- Do not assume an aggressive posture
- Make good eye contact, don’t stare
- Speak calmly, confidently, and slowly
- Never threaten the patient, either verbally or physically
Anything that dampens or obscures the true meaning of the message
Noise
Two types of questions
- Open-ended
- Close-ended
Encourage the patient to talk more or provide more information
Facilitation
Do not speak
Pause
Restating a patient’s statement made to you to confirm your understanding
Reflection
Be sensitive to the patient’s feeling and thoughts
Empathy
Ask the patient to explain what they meant by an answer
Clarification
Make the patient who is in denial or in a mental state of shock focus on urgent and life-critical issues
Confrontation
Restate the patient’s complaint to confirm your understanding
Interpretation
Provide factual information to support a conversation
Explanation
Provide the patient with an overview of the conversation and the steps you will take
Summary
10 Golden Rules to help calm and reassure your patient and provide a therapeutic rapport
- Make and keep eye contact with the patient
- Provide your name and use the patient’s proper name
- Tell the patient the truth
- Use 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
- If the patient is hard of hearing, face the person so that they can read your lips
- Allow time for the patient to answer or respond to questions
- Act and speak in a calm, confident manner
The ability to understand and manage your own emotions and properly respond to others’ emotions
Emotional intelligence
5 attributes of emotional intelligence
- Self-awareness
- Self-regulation
- Motivation
- Empathy
- Social skills
The ability to recognize your own emotions and how they affect your thoughts and behavior
Self-awareness
The ability to control impulsive emotions and behaviors and to manage emotions in positive ways
Self-regulation
The ability to motivate yourself and others in a positive direction, often deferring short-term rewards for long-term success
Motivation
The ability to understand the concerns, emotions, and needs of others by picking up on communication and social cues and clues
Empathy
The ability to develop and maintain positive rapport and relationships through effective communications
Social skills
Purposely focus your attention on the current moment, without blame and judgment for yourself or others
Mindfullness
Behavioral change stairway model
- Employ active listening
- Display empathy
- Build a rapport
- Exert influence
Never attribute ___ to old age
Altered mental status
Any communications where disruption will result in the failure of the task at hand
Mission-critical communications
The picture individuals have in their head of “what’s going on”
Mental model
For any team to work effectively together, all members must share a ___
Mental model
The goal of mission-critical communications
An efficient, effective, and error-free transfer of the mental model
What questions need to be answered for an individual or team to build a mental model?
- What is the focused priority for the patient?
- What is the history of prior care?
- What is the patient’s current state?
- What are the patient’s immediate needs?
The transfer of pertinent patient information and the responsibility for the patient’s care
Patient care handover or handoff
Giving the handover report
- Initiate eye contact
- Manage the environment
- Ensure the ABCs
- Provide a structured report
- Provide documentation
SBAR
Situation
Background
Assessment
Recap/Rx
SBAT
Situation
Background
Assessment
Treatment
Receiving the handover report
- Maintain eye contact
- Manage the environment
- Ensure understanding
- Summarize
- Gather supplementary patient documentation
Legal document used to record all aspects of the care your patient received, from initial dispatch to arrival at the hospital
Patient care report
Another term for the patient care report
Pre-hospital care report
Usually you will finish the PCR after ___
You have transferred care of the patient to an ED staff member
Two types of PCRs
Written
Electronic (ePCRs)
The minimum data set for NEMSIS
Both narrative components and check boxes
PCR functions
- Transfer of info and continuity of care
- Compliance and legal documentation
- Admin info
- Reimbursement
- Education
- Data collection for quality improvement and research
EMS documentation uses ___ time
Military
Two most common narrative formats for PCRs used in health care
CHART
SOAP
CHART
Chief complaint/concern
History
Assessments
(Rx) treatments
Transport
SOAP
Subjective
Objective
Assessment
Plan
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
CHART
Weakness of CHART
Somewhat difficult to learn
For location in CHART ___
Be specific with the type of location, don’t just say scene
Chief complaint vs chief concern
Complaint is what they are complaining of, but concern is the underlying problem that you are concerned about as an EMT
PCRs should include this information
- Time of events
- Assessment findings
- Emergency medical care provided
- Changes in the patient after treatment
- Observations at the scene
- Final patient disposition
- Refusal of care
- Staff person who continued care
Medicare and Medicaid payers will reimburse for ambulance transport only in the services are documented as being ___
Medically necessary
Means it would have been unsafe or impossible to transport the patient by any other means
Medically necessary
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
Health information exchange
HIE
Health information exchange
Most HIEs follow the ___ framework to improve patient care by giving health care providers rapid and universal access to accurate patient medical information
SAFR
SAFR
Search
Alert
File
Reconcile
MCI
Mass casualty incident
Any radio hardware containing a transmitter and receiver that is located in a fixed place
Base station
As assigned frequency used to carry voice and/or data communications
Channel
Used for specific point-to-point contact
Dedicated line
Dedicated line is also know as a ___
Hotline
A special base station radio that receives messages and signals on one frequency and then automatically retransmits them on a second frequency
Repeater
Electronic signals are converted into coded, audible signals
Telemetry
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
Scanner
