Transcript Document
Chapter 8
Medical
Communications
and Documentation
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Objectives
8.1 List the two types of medical
communications.
8.2 List the essential content that should be
included in all verbal communications,
using the acronym SAILER.
8.3 List the components for the following
methods used to complete a PCR:
a.
b.
BRADY
SOAP
CHEATED
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Objectives
8.4 List the characteristics of good report
writing using the acronym FACTUALOEC.
8.5 Describe and demonstrate how to correct
an error on a written report.
8.6 List two criteria that must be documented
on a patient refusal.
8.7 List four injuries or crimes that a
mandated reporter must report to
continued
authorities.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Objectives
8.8 Demonstrate how to complete a sample
patient care report with 100-percent
accuracy.
8.9 Demonstrate how to provide an oral
report.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Topics
Communications
Basics
Verbal and Written Communications
Notes / Reports / Forms
Characteristics of Good Report
Writing
Essential Content of Medical
Communications
Special Circumstances
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Communications Basics
Communication
is a process in which
a message is transmitted from a
sender to a receiver.
It is vital that the sender and receiver
have the same message.
◦ Restatement can help ensure that the
correct information has been received
Medical
communication is the transfer
of health care related information.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Verbal Communications
Transfers
information through spoken
words, and may be face to face or
device related
With patient / witnesses at the scene
With the first aid area via radio
With patrol help when it arrives
With personnel at the first aid area
◦ Hand-off report
BRADY
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Verbal Communications
Non-verbal
elements may affect the
message
Present essential information that is
clear, concise, and organized
SAILER acronym may be used to
radio patient information and request
assistance
Sender verifies receiver’s accuracy
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
SAILER
Sex
of patient
Age of patient
Incident – chief complaint
Location of the accident/patient
Equipment needed
Resources needed
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Written Communications
Documents
the patient encounter and
becomes a permanent record
May include informal notes as well as
formal documents
◦ Field care notes
◦ Incident report forms
◦ Patient care reports
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Written Communications
Accurately
describe facts associated
with the accident
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Written Communications
Copyright Edward McNamara
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Field Care notes
Taken
during the rescue operation
Essential current information
May become part of other reports
◦ Hand off report
◦ Formal accident report
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Accident Report Forms
May
be from NSAA, Insurance Co.,
Area – paper or computer generated
Record fundamental information
◦
◦
◦
◦
◦
◦
Patient identification
Cause of injury
Who was at the accident scene
Care given at the scene
Care given in the aid room
Further comments
Report
BRADY
corrections or additions
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Care Reports
Used
to record specific info about
medical care provided to the patient
◦ “If it isn’t documented, it didn’t happen"
May
be open, closed, or mixed in
format
Use SOAP / CHEATED
Complete reports are part of risk
management
BRADY
continued
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Care Reports
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Patient Care Reports
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
SOAP & CHEATED
Subjective
Objective
Assessment
Plan
BRADY
Chief
complaint
History
Examination
Assessment
Treatment
Evaluation
Disposition
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Characteristics of Good
Report Writing
Facts
Accurate
Complete
Terms are
Unbiased
Avoid slang
Legible
Organized
Error Free
Checked
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Essential Content of Medical
Communications
Age
and Gender
Chief complaint
History of present illness
Past medical history
Physical exam
Impression
Treatment
Response to treatment
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Special Circumstances
Refusal
of care
Incidents that must be reported to
authorities
Accident investigations
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Chapter Summary
Effective
medical communications is
one of the hallmarks of a highly skilled
OEC Technician.
Careful documentation is important
both for medical and legal reasons.
Medical communications include oral
communication and written
documentation.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Chapter Summary
Breakdowns
in the communication
process can create
misunderstandings and errors.
An oral hand-off report should take
less than 60 seconds to complete.
Patients who refuse medical
assistance must have the capacity to
do so.
continued
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
Chapter Summary
Thoroughly
document all patient
refusals.
If it isn’t documented, it didn’t
happen; document reports completely
and accurately.
Write good reports by being a
FACTUAL OEC Technician.
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ
THE
END
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UNsDVjCbo
BRADY
National Ski Patrol, Outdoor Emergency Care, 5th Ed.
©2012 by Pearson Education, Inc., Upper Saddle River, NJ