Transcript Communication and Documentation

Communication
and
Documentation
Emergency Medical Response
Lesson 11: Communication and Documentation
You Are the
Emergency Medical Responder
As the closest responders in the area, your police
unit is called to the scene where an elderly woman
has collapsed in front of her home. When you
arrive, a neighbor tells you that the woman
suddenly collapsed and tripped on the concrete
step in the walkway in front of her home. She is
now conscious but a little dazed, and you find that
she is also very frightened and apprehensive.
Emergency Medical Response
Components of
Radio Communication for EMS
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Base station – hub of communication
Mobile radios and data terminals in EMR vehicles
Portable radios – handheld
Repeaters- boost the range of portable radios
 Use “clear text” when talking on the radio
Emergency Medical Response
Communicating within the
Emergency Communications System
 Communications Center (dispatch)
 9-1-1 call center
 Point of contact between public and responders
 All conversations are recorded
 Medical Control
 Orders repeated word for word
 Medical Personnel
 Identify yourself as an EMR
Emergency Medical Response
Communicating within the
Emergency Communications System
 Receiving Facility
 Hospital
 Who you are
 How many patients arriving
 Patient characteristics
 Immediate history
 Care provided and patients response
 ETA
 Mobile Phone
 Cover longer distances than radio, superior sound
quality, direct communication between parties
Emergency Medical Response
Interpersonal Communication
 Show empathy: be understanding and culturally
sensitive to the thoughts, feelings and
experiences of another person
 Create positive relationships:
 Introduce yourself and team members
 Provide information about your role
 Eye level
 Listen
Emergency Medical Response
Activity
You arrive at the home of an elderly couple in
response to a 9-1-1 call for assistance. The
couple’s daughter called because her father, who
is bedridden due to a stroke, was having difficulty
breathing. The daughter is providing the
information because the elderly couple speaks very
little English.
Emergency Medical Response
Documentation
 Established by state regulations
 Documenting care is as important as providing
care
 The record is a legal document
 If you are called to court, the documentation
supports your action(s)
 Quality assurance practices
 Final step in providing care, accurate & complete
 If it’s not written down, it didn’t happen!
Emergency Medical Response
Functions of the
Prehospital Care Report (PCR)
 Primary function: ensures high-quality care
 Other functions:
 Legal document
 Educational and research tool
 Administrative tool – billing/reimbursment
 Confidentiality – falls within HIPAA
 Refusal of treatment
 Falsification is a serious offence
Emergency Medical Response
Prehospital Care Report Sample
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Emergency Medical Response
Sections of the
Prehospital Care Report
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2.
3.
4.
Run data
Patient data
Check boxes
Patient narrative
 Minimum data set
 Patient information gathered by EMR
 Administrative information
Emergency Medical Response
Sections of the
Prehospital Care Report
1. Run data - administrative information
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Time of incident
Arrival/departure of EMS at scene
ETA of EMS to receiving facility/transfer of care
EMS unit number
EMS crew members and certifications
Address of incident
Emergency Medical Response
Sections of the
Prehospital Care Report
2. Patient data – patient information
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Legal name
Age
Gender
Birth date
Home address
Billing/insurance information
Address of place of incident
Any care provided before EMS arrival
Emergency Medical Response
Sections of the
Prehospital Care Report
3. Check boxes
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Vital signs
Chief complaint
LOC
Appearance
Respiration rate
Emergency Medical Response
Sections of the
Prehospital Care Report
4. Patient narrative
 open ended section for a written description
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SAMPLE history
Chief complaint
MOI/NOI
Description of what happened? Own words
Emergency Medical Response
You Are the
Emergency Responder
As you assess the elderly patient, you learn that her chief
complaint is that she “blacked out” momentarily and fell.
The patient is afraid that she has broken her hip. She
has pain in her pelvis and is unable to move her left leg.
You give a verbal update to the EMS personnel who have
just arrived to take over medical care and transport the
patient.
Why is it important for communication to brief and concise?
What are some examples of effective interpersonal
communication? Why is it important to thoroughly
document your call, observations and actions?
Emergency Medical Response