Transcript Chapter09 - Hatzalah of Miami-Dade

9: Communications and Documentation
Cognitive Objectives (1 of 5)
3-7.1 List proper methods of initiating and terminating
a radio call.
3-7.2 State proper sequence for delivery of patient
information.
3-7.3 Explain the importance of effective
communication of patient information in the verbal
report.
3-7.4 Identify the essential components of the verbal
report.
Cognitive Objectives (2 of 5)
3-7.5 Describe attributes for increasing effectiveness and
efficiency of verbal communications.
3-7.6 State legal aspects to consider in verbal
communication.
3-7.7 Discuss the communication skills that should be
used to interact with the patient.
Cognitive Objectives (3 of 5)
3-7.8 Discuss the communication skills that should be
used to interact with the family, bystanders, and
individuals from other agencies while providing
patient care and hospital personnel, and the
difference between skills used to interact with the
patient and those used to interact with others.
3-7.9 List the correct radio procedures in the following
phases of a typical call: to the scene, at the scene,
to the facility, at the facility, to the station, at the
station.
Cognitive Objectives (4 of 5)
3-8.1 Explain the components of the written report and
list the information that should be included on the
written report.
3-8.2 Identify the various sections of the written report.
3-8.3 Describe what information is required in each
section of the prehospital care report and how it
should be entered.
3-8.4 Define the special considerations concerning
patient refusal.
Cognitive Objectives (5 of 5)
3-8.5 Describe the legal implications associated with the
written report.
3-8.6 Discuss all state and/or local record and reporting
requirements.
Affective Objectives
3-7.10 Explain the rationale for providing efficient and
effective radio communications and patient reports.
3-8.7 Explain the rationale for patient care
documentation.
3-8.8 Explain the rationale for the EMS system gathering
data.
3-8.9 Explain the rationale for using medical terminology
correctly.
Psychomotor Objectives
3-7.11 Perform a simulated, organized, concise radio
transmission.
3-7.12 Perform an organized, concise patient report
that would be given to the staff at a receiving
facility.
3-7.13 Perform a brief, organized report that would be
given to an ALS provider arriving at an incident
scene at which the EMT-B was already providing
care.
3-8.11 Practice completing a prehospital care report.
Communications and Documentation
• Essential components of prehospital care:
– Verbal communications are vital.
– Adequate reporting and accurate records ensure
continuity of patient care.
– Reporting and record keeping are essential aspects
of patient care.
Base Station Radios
• Transmitter and receiver located in a fixed place
• Power of 100 watts or more
• A dedicated line (hot line) is always open.
– Immediately “on” when you lift up the receiver
Mobile and Portable Radios
• Mobile radios installed in vehicle
– Range of 10 to 15 miles
• Portable radios hand-held
– Operate at 1 to 5 watts of power
Repeater-Based Systems
• Receives radio messages and retransmits
• A repeater is a base station able to receive low-power
signals.
Digital Equipment
• Some EMS systems use telemetry to send an ECG
from the unit to the hospital.
• Telemetry is the process of converting electronic
signals into coded, audible signals.
• Signals can be decoded by the hospital.
Cellular Telephones
• Low-powered portable radios that communicate
through interconnected repeater stations
• Cellular telephones can be easily scanned.
Other
• Simplex
– Push-to-talk communication
• Duplex
– Simultaneous talk-listen
• MED channels
– Reserved for EMS
Communication Quality
• Affected by power and location of antennas
• Changes in location can affect quality of transmission
• Check communication equipment at beginning of each
shift.
FCC Duties
• Allocate radio frequencies
• License base stations and assign call signs.
• Establish licensing standards and operating
specifications
• Establish limits on transmitter power output
• Monitor radio operations
Dispatch Responsibilities
• Screen and assign priorities
• Select and alert appropriate units to respond
• Dispatch and direct units to the location
• Coordinate response with other agencies
• Provide pre-arrival instructions to the caller
Information Received
from Dispatch
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Nature and severity of injury, illness, or incident
Location of incident
Number of patients
Responses by other agencies
Special information
Time dispatched
Communicating With Dispatch
• Report any problems during
run.
• Advise of arrival.
• Communicate scene size-up.
• Keep communications brief.
Insert EMTB9e Fig.
9-4.
Communicating
With Medical Control
• Radio communications facilitate contact between
providers and medical control.
• Consult with medical control to:
– Notify hospital of incoming patient.
– Request advice or orders.
– Advise hospital of special circumstances.
• Organize your thoughts before transmitting.
Patient Report
• Identification and level of services
• Receiving hospital and ETA
• Patient’s age and gender
• Chief complaint
• History of current problem
• Physical findings
• Summary of care given and patient response
Role of Medical Control
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May be off-line or online
Guides treatment of patients
May have to contact directly for orders
Many variations from system to system
Calling Medical Control
• Physician bases his or her instructions on report
received from the EMT-B.
• Never use codes while communicating.
• Repeat all orders received.
• Do not blindly follow an order that does not make
sense to you.
Special Situations
• Notify as early as possible.
• Estimate the potential number of patients.
• Identify special needs.
Standard Procedures and Protocols
• Keep transmission brief.
• Develop effective radio discipline.
• Identify the called unit, followed
by the calling unit.
– “Dispatch, this is Medic One.”
Reporting Requirements
• Acknowledge dispatch information.
• Notify arrival at scene.
• Notify departure from scene.
• Notify arrival at hospital or facility.
• Notify you are clear of the incident.
• Notify arrival back in quarters.
Maintenance of Equipment
• Radio equipment must be properly serviced.
• Nonfunctioning equipment should be removed from
service.
• Backup plans should be in place in case of
communication failure.
• Standing orders: Written documents signed by the
EMS system’s medical director.
Verbal Communication
• Essential part of quality patient care
• You must be able to find out what the patient needs
and then tell others.
• You are a vital link between the patient and the health
care team.
Components of an Oral Report
• Patient’s name, chief complaint, nature of illness,
mechanism of injury
• Summary of information from radio report
• Any important history not given earlier
• Patient’s response to treatment
• The vital signs assessed
• Any other helpful information
Communicating With Patients (1 of 2)
• Make and keep eye contact.
• Use the patient’s proper name.
• Tell the patient the truth.
• Use language the patient can understand.
• Be careful of what you say about the patient to
others.
Communicating With Patients (2 of 2)
• Be aware of your body language.
• Always speak slowly, clearly, and distinctly.
• If the patient is hearing impaired, speak clearly and
face him or her.
• Allow time for the patient to answer questions.
• Act and speak in a calm, confident manner.
Communicating With Geriatric
Patients
• Determine the person’s functional age.
• Do not assume that an older patient is senile or
confused.
• Allow patient ample time to respond.
• Watch for confusion, anxiety, or impaired hearing or
vision.
• Explain what is being done and why.
Communicating With Children
• Children are aware of what is
going on.
• Allow people or objects that
provide comfort to remain close.
• Explain procedures to children
truthfully.
• Position yourself on their level.
Communicating With HearingImpaired Patients
• Always assume that the patient has normal
intelligence.
• Make sure you have a paper and pen.
• Face the patient and speak slowly, clearly and
distinctly.
• Never shout!
• Learn simple phrases used in sign language.
Communicating With VisionImpaired Patients
• Ask the patient if he or she can see at all.
• Explain all procedures as they are being performed.
• If a guide dog is present, transport it also, if possible.
Communicating With Non-EnglishSpeaking Patients
• Use short, simple questions and answers.
• Point to specific parts of the body as you ask
questions.
• Learn common words and phrases in the non-English
languages used in your area.
Written Written
Communication
and Documentation and
Communication
Documentation
Minimum Data Set (1 of 2)
• Patient information
– Chief complaint
– Mental status
– Systolic BP (patients older than 3 years)
– Capillary refill (patients younger than 6 years)
– Skin color and temperature
– Pulse
– Respirations and effort
Minimum Data Set (2 of 2)
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Time incident was reported
Time that EMS unit was notified
Time EMS unit arrived on scene
Time EMS unit left scene
Time EMS unit arrived at facility
Time that patient care was transferred
Functions of the Prehospital
Care Report
• Prehospital care report serves six functions
– Continuity of care
– Legal documentation
– Education
– Administrative
– Research
– Evaluation and quality improvement
Types of Forms
• Written forms
• Computerized versions
• Narrative sections of the form
– Use only standard abbreviations.
– Spell correctly.
– Record time with assessment findings.
• Report is considered confidential.
Reporting Errors
• Do not write false statements on report.
• If error made on report then:
– Draw a single horizontal line through error.
– Initial and date error.
– Write the correct information .
Documenting Right of Refusal
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Document assessment findings and care given.
Have the patient sign the form.
Have a witness sign the form.
Include a statement that you explained the possible
consequences of refusing care to the patient.
Special Reporting Situations
• Be familiar with required reporting in your jurisdiction,
including:
– Gunshot wounds
– Animal bites
– Certain infectious diseases
– Suspected physical, sexual, or substance abuse
– Multiple-casualty incidents (MCI)