Chapter 4: Communications and Documentation Flashcards

1
Q

Describe Therapeutic Communication

A

Therapeutic communication uses various communication techniques and strategies, both verbal and nonverbal, to encourage patients to express how they are feeling and to achieve a positive relationship with the patient.

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2
Q

Describe the factors and strategies to consider
for therapeutic communication with patients.
(pp 119–133)

A
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3
Q

What is Ethnocentrism?

A

Ethnocentrism occurs when you consider your own cultural values to be more important when you are interacting with people of a different culture.

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4
Q

________ occurs when someone consciously or subconsciously forces their cultural values onto someone else because they believe their values are better.

A

Cultural imposition occurs when someone consciously or subconsciously forces their cultural values onto someone else because they believe their values are better.

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5
Q

Discuss the techniques of effective verbal
communication. (pp 122–133)

A

For effective communication to occur, the sender must take a thought, encode it into a message, and send the
message to the receiver. The receiver then decodes the message and sends feedback to the sender. A breakdown at
any of these steps can interfere with the intended message

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6
Q

Explain the skills that should be used to communicate with family members, bystanders, people from other agencies, and hospital personnel. (pp 122–133)

A
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7
Q

Discuss special considerations in communicat-
ing with older people, children, patients who are
hard of hearing, visually impaired patients, and
non–English-speaking patients. (pp 127–131)

A
  • be calm
  • Communicate in short understandable common English
  • Actively listen
  • Be honest
  • Explain what and why things are happening
  • Be prepared to improvise to communicate: body language or even pen and paper can go a long way
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8
Q

Describe the use of written communications
and documentation. (pp 133–146)

A
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9
Q

State the purpose of a patient care report (PCR)
and the information required to complete it.
(pp 134–143)

A
  • A PCR helps ensure efficient continuity of patient care.
  • The report serves the six functions listed here;
    1. Transfer of information and continuity of care
    A good PCR documents any changes in the patient’s condition on arrival at the hospital.
    Both objective and subjective information is included in this report.
    The following types of information are often collected on a PCR:
    Chief complaint or chief concern
    Mechanism of injury or nature of illness
    Level of consciousness (according to the AVPU scale) or mental status
    Vital signs
    Initial and ongoing assessment
    Patient demographics (age, gender, ethnic background)
    Transport information (how the patient was moved, reason for destination choice)
  1. Compliance and legal documentation
    If you are required to provide testimony concerning patient care, both you and your PCR will be used to present evidence.
    A neat, concise, well-written document—including correct spelling and grammar—will reflect good patient care.
  2. Administrative information
    Time the incident was reported
    Time the EMS unit was notified
    Time the EMS unit arrived at the scene
    Time the EMS unit left the scene
    Time the EMS unit arrived at the receiving facility
    Time the patient care was transferred
    Time the unit was back in service
  3. Reimbursement
    A PCR provides valuable information for patient billing, such as equipment usage, and other areas of administrative responsibility.
  4. Education
    The PCR report may also be used in an ongoing program for the evaluation of patient care, which aids education and research and contributes to quality improvement.
  5. Data collection for quality improvement and research
    Data may be obtained from the PCR to analyze causes, severity, and types of illness or injury requiring emergency medical care.
    These reports may also be used in ongoing evaluation of the quality of patient care.
    Although no universally accepted form exists, certain uniform data points are common in all areas so that national trends can be detected.
    PCRs are used by individual agencies to determine patterns of EMS responses.
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10
Q

Explain the legal implications of the PCR.
(pp 142–143)

A

The PCR when completed properly shows that you have met the standard of care and that continuity of care was efficient.

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11
Q

Describe how to document refusal of care,
including the legal implications. (pp 143–146)

A

If you can’t persuade the patient to proceed with treatment, document:
- Any patient assessment findings
- Emergency medical care given
- Your efforts to obtain consent
- The patient’s response to your efforts

Have the patient sign a refusal form.

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.

Inform online medical control when patients refuse care.

Even if a patient refuses care, complete the PCR.
Document the advice you gave regarding the risks associated with refusal of care.
Report clinical information, such as the level of consciousness (LOC), showing the competency of the person refusing care.
Note pertinent patient comments.
Note any medical advice given to the patient by the physician or medical control through phone or radio.
Include a description of the care that you wished to provide for the patient.
Anytime a patient refuses any part of the standard treatment, document it in the PCR.

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12
Q

Describe the basic principles of the various
types of communications equipment used in
EMS. (pp 146–150)

A
  • Base station - A base station is any radio hardware containing a transmitter and a receiver that are located in a fixed place.
  • mobile and portable radios - A mobile radio is installed in a vehicle and operates at lower power than a base station
  • repeater - A repeater is a special base station radio that receives messages and signals on one frequency and then automatically re-transmits them on a second frequency.
  • digital equipment - With telemetry, electronic signals are converted into coded, audible signals that can be transmitted by radio or telephone to a receiver with a decoder at the hospital. You can send heart rhythm and cardiac information via radio to the hospital
  • cellular/satellite telephones
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13
Q

List the correct radio procedures in the
following phases of a typical call: initial receipt
of call, en route to call, on scene, arrival at
hospital (or point of transfer), and return to
service. (pp 151–153)

A

initial receipt - acknowledge/ respond

en route - request assistance with directions, additional resources etc.

on scene - report arrival, check in, request resources if necessary, report departure

arrival at point of transfer - report arrival

return to service - notify dispatch you are ready to roll

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14
Q

List the proper sequence of information to
communicate in radio delivery of a patient
report. (pp 153–156)

A
  • Your unit identification and level of services
  • The receiving hospital and your estimated time of arrival
  • The patient’s age and gender
    The patient’s name should not be given over the radio because it may be overheard. This would be a violation of the patient’s privacy.
  • The patient’s chief complaint or your perception of the problem and its severity
  • A brief history of the patient’s current problem
  • Other important history information that may pertain to the current problem
  • A brief report of physical findings, including:
    Level of consciousness
    Patient’s general appearance
    Pertinent abnormalities
    Vital signs
  • A brief summary of the care given and any patient response
  • A brief description of the patient’s response to the treatment provided
  • Determine whether the receiving facility has any additional questions or orders.
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15
Q

What is emotional intelligence?

A

Emotional intelligence is the ability to understand and manage your own emotions and properly respond to others’ emotions.

It can help you defuse conflict, build a rapport, communicate more effectively, and manage difficult situations.
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16
Q

WHat are the 5 attributes of emotional intelligence?

A

Emotional intelligence has five attributes:

  • Self-awareness. The ability to recognize your own emotions and how they affect your thoughts and behavior.
  • Self-regulation. The ability to control impulsive emotions and behaviors and to manage emotions in positive ways.
  • Motivation. The ability to motivate yourself and others in a positive direction, often deferring short-term rewards for long-term success.
  • Empathy. The ability to understand the concerns, emotions, and needs of others by picking up on communication and social cues and clues.
  • Social skills. The ability to develop and maintain positive rapport and relationships through effective communications.
17
Q

What is the behavioral change stairway and what are its steps?

A

A method of deescalating used for hostage negotiations by the FBI:

  1. Employ active listening. Carefully listen to what the other person has to say, and let the person know you are doing so. Acknowledge what the person is saying, and do not interrupt, disagree, or give commands.
  2. Display empathy. Use your emotional intelligence to understand the patient’s perspective. You do not have to agree with the person or condone his or her actions, but you need to understand where the person is coming from and what the person wants.
  3. Build a rapport. Once you have listened to the person and understand where he or she is coming from, it is much easier, especially in a crisis, to empathize with the person and “speak the person’s language.”
  4. Exert influence. Look at realistic solutions to move the situation forward in a positive way. Understanding the person’s perspective as well as your own needs, consider how you can move forward in a way the person will understand. Initiate behavior change: Propose a solution that makes sense to the other person and is acceptable to you.
18
Q

_________ are any communications whose disruption will result in the failure of the task at hand.

A

Mission-critical communications are any communications whose disruption will result in the failure of the task at hand.

19
Q

A mental model is the picture individuals have in their head of “what’s going on.” For any team to work effectively together, all members must share the same mental model.

What 4 questions do you need to answer to share an effective mental model?

A

For an individual health care provider or a team to build a mental model, you need to answer these four questions:

  1. What is the focused priority for the patient? (What is the crux of the problem?)
  2. What is the history of prior care? (What got us to this point?)
  3. What is the patient’s current state? (Where are we right now?)
  4. What are the patient’s immediate needs? (What is the very next thing that needs to happen?)
20
Q

Describe each step of the SBAT mnemonic.

A
  1. Situation: a concise statement of the problem
  2. Background: relevant, brief information about the patient situation
  3. Assessment: your assessment findings and what you think
  4. Treatment: care that has been provided to the patient

Consider the following example of a structured report that uses the SBAT format to focus on priority issues, prior care, current state, and immediate needs:

S This is a trauma alert. We have a hypotensive 28-year-old female involved in a motor vehicle collision with an unstable pelvis and right-side open tibia/fibula fracture.

B Patient was struck by a motor vehicle at approximately 35 mph approximately 20 minutes ago.

A She is conscious and alert but slow to respond. Vital signs are BP, 88/48; pulse, 124 and irregular; respirations, 24; and SaO2, 96%. Head-to-toe finds injuries to the pelvis and the left leg as well as minor abrasions, but no other significant findings. Her only significant medical history is asthma.

T We applied oxygen and stabilized her pelvis and left leg, and both have good distal PMS. Do you have any questions?

21
Q

What is a PCR?

A

The patient care report (PCR), also known as the prehospital care report, is the legal document used to record all aspects of the care your patient received.

22
Q

What does medically necessary mean and why does it matter?

A

Medically necessary means it would have been unsafe or impossible to transport the patient by any other means.

Without this Medicare and Medicaid only reimburse if the treatments were medically necessary.