Communication & Documentation

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 Communication

The activity of conveying information

Emergency Medical Responder Course SL 7-5

Rev. April 2014
5
 Types of Communication
1. Verbal
2. Nonverbal
3. Written
4. Visual

Emergency Medical Responder Course SL 7-6

Rev. April 2014
6
 Strategies for Effective
Communication
1. Speak clearly and use words and terminology
that the receiver will understand.
2. Keep an open mind and resist the urge to be
defensive.
3. Become an active listener.
4. Be assertive when appropriate, especially
when safety is at stake.

Emergency Medical Responder Course SL 7-9

Rev. April 2014
10
 Strategies for Effective
Communication
5. Remain aware of the influence that body
language plays in effective communication.
6. Accept the reality of miscommunication.

Emergency Medical Responder Course SL 7-10

Rev. April 2014
11
Therapeutic Communication
The face-to-face communication process that
focuses on advancing the physical and
emotional well-being of a patient.

Emergency Medical Responder Course SL 7-12

Rev. April 2014
13
Three Objectives of Therapeutic
Communication
1. Collecting information
2. Assessing behaviour
3. Educating

Emergency Medical Responder Course SL 7-13

Rev. April 2014
14
 Communication system

1. System components
a. Base station
b. Mobile two-way radios (transmitter/
receivers)
c. Portable radios (transmitter/receivers)
d. Repeater/base station
e. Digital radio equipment
f. Cellular telephones

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2. Communication with medical direction

(1) When speaking on the radio:

• Radio is on and volume is properly adjusted.
• Listen
• Press the (PTT) button and wait for one second before
speaking.
• Speak with lips about 2 to 3 inches from the microphone.
• Address the unit being called, then give the name of the unit
where the transmission is originating from.
• The unit being called will signal that the transmission should
start by saying "go ahead”
• Speak clearly and slowly, in a monotone voice.
• Keep transmissions brief.
• Use clear text. 18
• Avoid codes.
• Avoid meaningless phrases
• Courtesy is assumed
• When transmitting a number that might be confused give the
number, then give the individual digits.
• Do not give a patient's name over the air.
• Be careful to remain objective and impartial in describing
patients.
• An EMT-Basic rarely acts alone: Use "we" instead of "I."
• Do not use profanity on the air.
• Avoid words that are difficult to hear
• When the transmission is finished, indicate this by saying "over.”
• Avoid codes, especially those that are not standardized.
• Avoid offering a diagnosis of the patient's problem.
• Use EMS frequencies only for EMS communication.
• Reduce background noise as much as possible. 19
(2) Notify the dispatcher when the unit leaves the scene.

(3 The essential elements of such a report:

(a) Identify unit and level of provider
(b) Estimated time of arrival
(c) Patient's age and sex
(d) Chief complaint
(e) Brief, pertinent history of the present illness
(f) Major past illnesses
(g) Mental status
(h) Baseline vital signs
( i ) Pertinent findings of the physical exam
(j) Emergency medical care given
(k) Response to emergency medical care 20
(4) After giving this information, the
EMR will continue to assess the
patient.

(5) Arrival at the hospital

(6) Leaving the hospital for the station

(7) Arrival at the station

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B. Verbal communication
1. After arrival at the hospital
a. Introduce the patient by name
b. Summarize the information given over the radio:
(1) Chief complaint
(2) History that was not given previously
(3) Additional treatment given en route
(4) Additional vital signs taken en route
c. Give additional information

C. Written communication

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D. Interpersonal communication

1. Make and keep eye contact with the patient.

2. When practical, position yourself at a level lower than
the patient.
3. Be honest with the patient.
4. Use language the patient can understand.
5. Be aware of your own body language.
6. Speak clearly, slowly and distinctly.
7. Use the patient's proper name
8. If a patient has difficulty hearing, speak clearly with lips
visible.
9. Allow the patient enough time to answer a question
before asking the next one.
10. Act and speak in a calm, confident manner. 23
• Rescue One : Central Dispatch, this is rescue One with a request
• Central Dispatch : Rescue One, Central Dispatch, go ahead with
your request
• Rescue One : Central Dispatch, Rescue One, can you repeat the
address for our call?
• Central Dispatch : Rescue One, Central Dispatch, you are
responding to Multi Purporse Building, NFTI, 4029 Camp Vicente
Lim, Calamba, Laguna City.
• Rescue One: Central Dispatch Rescue One, confirming 4029
Camp Vicente Lim
• Central Dispatch : Rescue One, That’s affirmative…

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“What is not written is not done.”

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 Documentation

A. Minimum data set

1. Patient information

2. Administrative information

3. Accurate and synchronous clocks

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B. Pre-hospital care report

1. Functions

a. Continuity of care
b. Legal document
c. Educational
d. Administrative
e. Research
f. Evaluation and continuous quality improvement

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 2. Use
a. Types
(1) Traditional written form with check boxes and a section
for narrative.
(2) Computerized version where information is filled in by
means of an electronic clipboard or a similar device.

b. Sections
(1) Run data
(2) Patient data
(3) Check boxes
(4) Narrative section (if applicable)
(5) Other state or local requirements

c. Confidentiality

d. Distribution SL 7-16
Rev. April 2014
28
Emergency Medical Responder Course SL 7-20
Rev. April 2014
29
Emergency Medical Responder Course SL 7-21
Rev. April 2014
30
 Final Report Format (Sample)
INCIDENT INFORMATION
Incident No.: Date:
Crew Member Names:
1. _________________________________ 3. _________________________________

2. _________________________________ 4. _________________________________

Patient __________ of __________ Unit No. ____________ Station No.

____________

Received Call (time): _______________________ Contact with Patient (time): __________________

Dispatched (time): __________________________ Alerted Hospital (time): _____________________

En-route (time): ____________________________ Transport Patient (time): _____________________

Arrival on Scene: __________________________ Arrival at Destination (time): _________________

Unit Available (time): ________________________

Incident Address:__________________________________________________________________________

________________________________________________________________________________________

Nature of the Call: _____________________________________________________________________

Other agencies involved:____________________________________________________________________

Agency transporting patient: _________________________________________________________________

PATIENT INFORMATION

Last Name: _______________________________ First Name, M.I.: __________________________

Incident Address:__________________________________________________________________________

________________________________________________________________________________________

Identification No.: __________________________ Date of birth: ________ / ________ / ________

Sex (circle one): M F Age: ____________________ Estimated weight:

_______________
VITAL SIGNS BASELINE

Airway: __________________________________ Respirations: _____________________________

Temperature: ______________________________ Skin Color: _______________________________

Skin: ____________________________________ Pupils: __________________________________

Palpable Pulses Time: ___________________________________

Radial: __________________________________ Pulse: ___________________________________

Carotid: __________________________________ Respirations: _____________________________

Other: ___________________________________ Blood Pressure: __________________________

Emergency Medical Responder Course SL 7-17

Rev. April 2014
31
 HISTORY

Medical History: _______________________________________________________________________

____________________________________________________________________________________

Chief complaints: ______________________________________________________________________

____________________________________________________________________________________

Allergies: ____________________________________________________________________________

Medications/Treatment: ________________________________________________________________

____________________________________________________________________________________
VITAL SIGNS

Time Pulse Resp. Blood Pres. Comments

NARRATIVE

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________
PATIENT REFUSAL OF TREATMENT

________________________________________________
Patient’s Signature

________________________________ ________________________________
Witness 1 Signature Witness 2 Signature

MFR Officer in Charge

________________________________ ________________________________
Printed Name Signature

Emergency Medical Responder Course SL 7-18

Rev. April 2014
32
3. Falsification issues

a. When an error of omission or commission

occurs, the EMT Basic should not try to cover it
up

b. may lead not only to suspension or revocation

c. Specific areas of difficulty

(1) Vital signs
(2) Treatment

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C. Documentation of patient refusal
1. Competent adult patients have the right to refuse
treatment.

2. Before the EMR leaves the scene, however, he should:

a. persuade the patient
b. Ensure the patient is able to make a rational,
informed decision
c. Inform the patient why he should go and what
may happen to him if he does not.
d. Consult medical direction
e. If the patient still refuses, have the patient sign a
refusal form.
f. Have a witness.
g. Complete the pre-hospital care report. 34
D. Special Situations/reports/incident
reporting
1. Correction of errors
2. Multiple casualty incidents (MCI)
3. Special situation reports
4. Continuous quality improvement
5. Information gathered from the pre-hospital
care report can be used to analyze various
aspects of the EMS system.
6. This information can then be used to improve
different components of the system and prevent
problems from occurring.
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Correcting Data

Emergency Medical Responder Course SL 7-19

Rev. April 2014
36