Transcript Poisoning and Substance Abuse

Chapter 4
Communications and
Documentation
National EMS Education
Standard Competencies (1 of 3)
Preparatory
Uses simple knowledge of the emergency
medical services (EMS) system, safety/wellbeing of the emergency medical responder
(EMR), and medical/legal issues at the scene
of an emergency while awaiting a higher level
of care.
National EMS Education
Standard Competencies (2 of 3)
Documentation
• Recording patient findings
EMS System Communication
Communication needed to:
• Call for resources
• Transfer care of the patient
• Interact within the team structure
National EMS Education
Standard Competencies (3 of 3)
Therapeutic Communication
• Principles of communicating with patients in
a manner that achieves a positive
relationship
• Interviewing techniques
Medical Terminology
Uses simple medical and anatomic terms.
Introduction
• Communications are important
during every phase of a call.
– The dispatcher must communicate the location
and type of call to responders.
– EMRs need to communicate with patients,
bystanders, family members, dispatchers, and
members of the public safety community.
– After a call, you must document the condition of
the patient and the treatment given.
Communications Systems
and Equipment (1 of 2)
• The purpose of a communications
system is to relay information from one
location to another when it is impossible to
communicate face to face.
• The results of using a communication
system will be only as accurate as the
information that is put into the system.
Communications Systems
and Equipment (2 of 2)
• Communications systems can be divided
into two categories:
– Those that transmit voice communications
– Those that transmit data
Voice Systems (1 of 3)
• Voice communications systems transmit the
spoken word from one location to another.
• Radio systems
– Regulated by the Federal Communications
Commission (FCC)
– Frequencies are assigned according to the
function of the organization.
Voice Systems (2 of 3)
• Radio systems
(cont’d)
– Types of radios:
• Base station
• Mobile radio
• Portable radios
• Repeater
Voice Systems (3 of 3)
• Telephone systems
– Primarily convey voice communications
– Landline phone systems: tied together through
an above-ground or below-ground hardwired
system
– Cellular phones: rely on radio waves between a
cellular phone and a cellular tower to send and
receive phone messages
Data Systems (1 of 2)
• Data can be
transmitted through
radio systems or
phone systems.
– Paging systems can
transmit text
messages or voice
communications.
– Mobile data terminals
(MDTs) transmit data
messages through a
radio system.
Data Systems (2 of 2)
• Fax machines use phone lines or radio
systems to send written data.
• Telemetry is used by ALS providers to
transmit ECGs and other patient data to
online medical control.
• E-mail is used to transmit a wide variety of
messages.
The Functions of Radio
Communications (1 of 9)
• Dispatch
– Dispatch may be voice, text messaging, or an
MDT to alert responders to an emergency.
– It is your duty to keep your equipment ready to
receive a call when you are on duty.
– If you are unsure that all information has
been received correctly, ask the dispatcher to
repeat it.
The Functions of Radio
Communications (2 of 9)
• Response to the
scene
– Learn how to use your
map books or GPS.
– The dispatcher may give
you further information
while you are en route to
the scene.
– If you are delayed or
encounter any problems,
notify dispatch.
The Functions of Radio
Communications (3 of 9)
• Arrival at the scene
– Perform a visual survey of the scene.
– Give the communications center a concise
verbal picture of the scene:
• Location and type of incident
• Any hazards present
• Number of patients
• Any additional assistance required
The Functions of Radio
Communications (4 of 9)
• Update responding EMS units
– Your report should include:
• Age and sex of the patient
• Chief complaint
• Level of responsiveness
• Status of airway, breathing, and circulation
• Transferring care to other EMS personnel
– Provide EMTs or paramedics with a “hand-off”
report.
The Functions of Radio
Communications (5 of 9)
• Transferring care (cont’d)
– Use the same approach you follow during
patient assessment:
• Provide the age and sex of the patient.
• Describe the history of the incident.
• Describe the patient’s chief complaint.
• Describe the patient’s level of
responsiveness.
• Describe how you found the patient.
The Functions of Radio
Communications (6 of 9)
• Transferring care (cont’d)
– Patient assessment: (cont’d)
• Report the status of the patient’s vital signs,
airway, breathing, and circulation.
• Describe the results of the physical
examination.
• Report any pertinent medical conditions
using the SAMPLE format.
• Report the interventions provided and the
patient’s response to them.
The Functions of Radio
Communications (7 of 9)
• Transferring care (cont’d)
– Online medical control is generally used by
EMTs and paramedics to:
• Secure permission to perform certain skills
• Get direction regarding patient care
• Give patient care reports to the hospital
The Functions of Radio
Communications (8 of 9)
• Postrun activities
– After you have transferred care, you need to
report your status to your communications
center.
– Let the communications center know how long it
will take you to get your unit ready for service
and when you will be available for another call.
The Functions of Radio
Communications (9 of 9)
Verbal Communications (1 of 2)
• Good communication means that the
person receiving the message understands
exactly what the person who sent the
message meant.
– Effective communication requires feedback.
– The receiver needs to communicate to the
sender that the message has been received
and understood.
Verbal Communications (2 of 2)
• Both external and internal distractions can
hinder effective communication.
– External distractions: noise and other people
talking
– Internal distractions: letting yourself think about
a personal matter while on scene
Guidelines for Effective
Communications With Patients (1 of 3)
• Introduce yourself by
name and title.
• Ask the patient’s name
and use it.
• Make and keep eye
contact.
• Use language the patient
can understand.
• Speak slowly, clearly, and
distinctly.
Guidelines for Effective
Communications With Patients (2 of 3)
• Tell the truth.
• Allow time for the patient to respond.
• Limit the number of people talking with the
patient.
• Be aware of your body language.
• Act and speak in a calm, confident manner.
Guidelines for Effective
Communications With Patients (3 of 3)
• Respect the cultural norms of the patient.
• Use open-ended and closed-ended
questions appropriately.
• Treat all patients as if they were members
of your family.
Communicating With Patients
With Special Needs (1 of 10)
• Hearing-impaired patients
– Identify yourself by showing the patient your
patch or badge.
– Touch the patient.
– Face the patient when you speak so he or she
can see your lips and facial expressions.
– Speak slowly and distinctly; do not shout.
– Watch the patient’s face for expressions of
understanding or uncertainty.
Communicating With Patients
With Special Needs (2 of 10)
• Hearing-impaired patients (cont’d)
– Repeat or rephrase your comments in clear,
simple language.
– If all else fails, write down your questions.
Communicating With Patients
With Special Needs (3 of 10)
• Visually impaired patients
– Tell the patient what is happening, identify
noises, and describe the situation and
surroundings.
– Find out the patient’s name and use it
throughout your examination and treatment.
– If the patient has a service dog, try to keep the
patient and dog together.
– It is not necessary to talk louder.
Communicating With Patients
With Special Needs (4 of 10)
• Non–English-speaking patients
– Determine how much English the patient
speaks, if any, and try to find an interpreter.
– Supplement your questions with hand gestures,
finger-pointing, and facial expressions.
Communicating With Patients
With Special Needs (5 of 10)
• Geriatric patients
– Do not assume that all older patients have
physical or mental impairments.
– Assess all patients carefully and give them time
to respond to your questions.
Communicating With Patients
With Special Needs (6 of 10)
• Pediatric patients
– Familiar objects and faces can help reduce fear
for children.
– Talk to the parents and the child as much as
possible and tell them what is happening.
– Ask a parent to hold the child if the illness or
injury permits.
– Tell the child your first name and explain what
you are doing.
Communicating With Patients
With Special Needs (7 of 10)
• Pediatric patients
(cont’d)
– Squat, kneel, or sit
down to the child’s
level and establish
eye contact.
– Be honest.
Communicating With Patients
With Special Needs (8 of 10)
• Developmentally disabled patients
– Ask the family about the patient’s typical level of
communication.
– Speak slowly, using short sentences and simple
words.
– You may need to repeat or rephrase statements
several times until the patient understands what
you want.
Communicating With Patients
With Special Needs (9 of 10)
• Persons displaying disruptive behavior
– Assess the situation; try to determine the cause
of the patient’s disruptive behavior.
– Protect the patient and yourself.
– Stay between the patient and an exit.
– Do not take your eyes off the patient or turn
your back.
– If the patient has a weapon, stay clear and wait
for law enforcement personnel.
Communicating With Patients
With Special Needs (10 of 10)
• Persons displaying disruptive behavior
(cont’d)
– As soon as your personal safety is assured,
carry out the appropriate emergency medical
care.
– You cannot take a disruptive patient to the
hospital against his or her wishes.
Medical Terminology (1 of 3)
• Collection of technical terms used by
medical personnel to:
– Identify anatomic parts of the body
– Specify illnesses
– Designate injuries
– Indicate treatments
Medical Terminology (2 of 3)
• Your job as an EMR is to communicate your
message to other medical providers as
clearly as possible.
– Do not use medical terms if you are unsure of
their meaning.
– As new terminology is introduced, look at the
construction of each word.
– Learn commonly occurring prefixes and
suffixes.
Medical Terminology (3 of 3)
Documentation (1 of 4)
• Documentation is a process for verifying
your actions using written records or
computer-based records.
• Proper documentation includes:
– The age and sex of the patient
– The history of the incident
– The condition of the patient when found
– The patient’s description of the injury/illness
Documentation (2 of 4)
• Proper documentation includes: (cont’d)
– The patient’s chief complaint
– The patient’s level of responsiveness
– The status of initial and subsequent vital signs
– The results of the physical examination
– Pertinent medical conditions using the SAMPLE
format
– The treatment you gave the patient
Documentation (3 of 4)
• Proper documentation includes: (cont’d)
– Any change in the patient’s condition
– The agency and personnel who took over
treatment
– The following times:
• The time you were dispatched
• The time you arrived on the scene
• The time other providers arrived on the scene
• The time you departed the scene
Documentation (4 of 4)
• Proper documentation includes: (cont’d)
– Any reportable conditions present
– Any infectious disease exposure
– Anything unusual about the case
– Any other helpful facts
• Complete your patient care report as soon
as possible after each call.
Summary (1 of 4)
• Communications systems allow you to relay
information from one location to another
when it is impossible to communicate face
to face. Excellent communication skills are
crucial during every phase of a call.
Summary (2 of 4)
• In addition to radio and oral
communications, you must have excellent
person-to-person communication skills. You
should be able to effectively interact with
the patient and any family members,
friends, or bystanders.
• Your body language and attitude are very
important in gaining the trust of both the
patient and the family.
Summary (3 of 4)
• You must take special care of individuals
such as children, geriatric patients, hearingimpaired and visually impaired patients,
non–English-speaking patients,
developmentally disabled patients, and
persons displaying disruptive behavior.
Summary (4 of 4)
• Along with your radio report and oral report,
you must complete a formal written hand-off
report that will be given to other EMS
professionals at the scene.
Review
1. When communicating with a sick or injured
person, it is important to:
A. use terms such as “dear” and “buddy” when
addressing the patient.
B. only use medical terminology.
C. ask the patient as little as possible.
D. maintain eye contact with the patient when
you can.
Review
Answer:
D. maintain eye contact with the patient
when you can.
Review
2. Which of the following would be considered
good communication?
A. You talk louder so you can be heard over the
television.
B. You initiate care without telling the patient
what you are doing.
C. You assess the patient while thinking about
your last call.
D. You minimize distractions during your
conversation with the patient.
Review
Answer:
D. You minimize distractions during your
conversation with the patient.
Review
3. When caring for a pediatric patient, you
should consider:
A. separating the child from the parents to avoid
upsetting them.
B. speaking in an authoritative tone.
C. allowing the parent to hold the child, if the
situation permits it.
D. performing painful procedures without giving
the child any warning.
Review
Answer:
C. allowing the parent to hold the child, if
the situation permits it.
Credits
• Background slide image (ambulance):
© Comstock Images/Alamy Images
• Background slide images (non-ambulance):
© Jones & Bartlett Learning. Courtesy of
MIEMSS.