Chapter 4: Communications and Documentation Flashcards
Describe Therapeutic Communication
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.
Describe the factors and strategies to consider
for therapeutic communication with patients.
(pp 119–133)
What is Ethnocentrism?
Ethnocentrism occurs when you consider your own cultural values to be more important when you are interacting with people of a different culture.
________ occurs when someone consciously or subconsciously forces their cultural values onto someone else because they believe their values are better.
Cultural imposition occurs when someone consciously or subconsciously forces their cultural values onto someone else because they believe their values are better.
Discuss the techniques of effective verbal
communication. (pp 122–133)
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
Explain the skills that should be used to communicate with family members, bystanders, people from other agencies, and hospital personnel. (pp 122–133)
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)
- 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
Describe the use of written communications
and documentation. (pp 133–146)
State the purpose of a patient care report (PCR)
and the information required to complete it.
(pp 134–143)
- 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)
- 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. - 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 - Reimbursement
A PCR provides valuable information for patient billing, such as equipment usage, and other areas of administrative responsibility. - 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. - 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.
Explain the legal implications of the PCR.
(pp 142–143)
The PCR when completed properly shows that you have met the standard of care and that continuity of care was efficient.
Describe how to document refusal of care,
including the legal implications. (pp 143–146)
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.
Describe the basic principles of the various
types of communications equipment used in
EMS. (pp 146–150)
- 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
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)
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
List the proper sequence of information to
communicate in radio delivery of a patient
report. (pp 153–156)
- 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.
What is emotional intelligence?
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.
