Chapter 15 Communication and Documentation

Question 1

Key Terms

a two-way radio at a fixed site such as a hospital or dispatch center

Answer 1

Base Station

Question 2

Key Terms

a phone that transmits through the air instead of over wires so the phone can be transported and used over a wide area

Answer 2

Cell Phone

Question 3

Key Terms

an abbreviated form of the PCR than an EMS crew can leave at the hospital when there is not enough time to complete the PCR before leaving

Answer 3

Drop Report (or transfer report)

Question 4

Key Terms

a two-way radio that is used or affixed in a vehicle

Answer 4

Mobile Radio

Question 5

Key Terms

a handheld two-way radio

Answer 5

Portable Radio

Question 6

Key Terms

a device that picks up signals from lower-power radio units, such as mobile and portable radios, and retransmits them at a higher power. It allows low-power radio signals to be transmitted over longer distances

Answer 6

Repeater

Question 7

Key Terms

the process of sending and receiving data wirelessly

Answer 7

Telemetry

Question 8

Key Terms

the unit of measurement of the output power of a radio

Answer 8

Watt

Question 9

Short Answer

List the steps of a medical radio report, and describe the communication that may be necessary during each part.

Answer 9

The steps of a medical radio report are:

• Unit identification and level of provider (“Memorial Hospital, this is Community BLS Ambulance 6 en route to your location…”)
• Estimated time of arrival (…with a 15-minute ETA.”)
• Patient’s age and sex (“We are transporting a sixty-eight-year-old male patient…”)
• Chief complaint (“…who complains of pain in his abdomen.”)
• Brief, pertinent history of the present illness (“Onset of pain was two hours ago and is accompanied by slight nausea.”)
• Major past illnesses (“The patient has a history of high blood pressure and arthritis.”)
• Mental status (“He is alert and oriented, never lost consciousness.”)
• Baseline vital signs (His vital signs are pulse 88, regular and full; respiration 20 and unlabored; skin normal; and blood pressure 134 over 88.”)
• Pertinent findings of the physical exam (“Our exam revealed tenderness in both upper abdominal quadrants. They did not appear rigid.”)
• Emergency medical care given (“For care, we have placed him in a position of comfort.”)
• Response to emergency medical care (“The level of pain has not changed during our care. Mental status has remained unchanged. Vital signs are basically unchanged.”)
• If your system requires, or if you have questions, contact medical direction. (“Does medical direction have any orders?”)

Question 10

Short Answer

List several guidelines for effective interpersonal communication with patients.

Answer 10

Effective interpersonal communication with patients should include these qualities:

 - Use eye contact.
 - Be aware of your position and body language.
 - Use language the patient can understand.
 - Be honest.
 - Use the patient’s proper name.
 - Listen.

Question 11

Short Answer

Explain what is meant by ”objective” and “subjective” information in the narrative portion of the prehospital care report. Explain what is meant by a “a pertinent negative.”

Answer 11

Subjective information is that which is from an individual point of view—the patient, bystanders, even the EMT (e.g., patient says “I feel like I’ve got the flu.”). Objective information is that which is observable, measurable, and verifiable (e.g., vital signs). A pertinent negative is something that is not present but that is important to note (e.g., “The patient states that her chest pain does not radiate.”).

Question 12

Short Answer

Explain how spelling and the use of codes, abbreviations, and medical terms relate to writing a clear and accurate narrative report.

Answer 12

Written reports that are unclear to others may cause harmful errors in patient care. They also make it hard for the quality improvement team to conduct reviews and research.

Question 13

Short Answer

List some important steps to take and information to include when documenting a patient refusal.

Answer 13

Important steps to take and important items to document when a patient is refusing care or transportation to the hospital include:

• Try again to persuade the patient to go to the hospital.
• Ensure the patient is able to make a rational, informed decision (e.g., not under the influence of alcohol or other drugs or illness/injury effects).
• Inform the patient why he should go and what my happen to him if he does not.
• Consult medical direction as directed by local protocols.
• If the patient still refuses, document any assessment finding and emergency medical care given, and have the patient sign a refusal form.
• Have a family member, police officer, or bystander sign the form as a witness. If the patient refuses to sign the refusal form, have a family member, police officer, or bystander sign the form verifying that the patient refused to sign.