Communications and Documentation:. Chapter 9. Communications and Documentation. Essential components of prehospital care: Verbal communications are vital. Adequate reporting and accurate records ensure continuity of patient care.
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Communications and Documentation: Chapter 9
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 Receivedfrom Dispatch • 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.
CommunicatingWith 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 • 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 • 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. • 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 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 Hearing-Impaired 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 Vision-Impaired 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-English-Speaking 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.
Minimum Data Set • 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 • 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 PrehospitalCare 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 • 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.