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Emergency Medical Technician > Communications & Documentation > Flashcards

Communications & Documentation Flashcards

1
Q

The transmission of information from on person to another

A

Communication

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2
Q

Types of communication

A
  1. Written
  2. Verbal
  3. Nonverbal
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3
Q

Written or electronically recorded portion of your patient care interaction that becomes part of the patient’s permanent medical record

A

Documentation

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4
Q

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

A

Therapeutic communications

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5
Q

People tend to translate the messages they receive using their own ___

A

Worldview

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6
Q

Occurs when you consider your own cultural values as more important when you are interacting with people of a different culture

A

Ethnocentrism

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7
Q

When one person imposes their beliefs, values, and practices on another because they believe their ideals are superior

A

Cultural imposition

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8
Q

When you are treating a potentially hostile patient, it is important that you understand and be aware of your own ___

A

Body language

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9
Q

Steps to dealing with a hostile patient

A
  1. Assess the safety of the scene
  2. Do not assume an aggressive posture
  3. Make good eye contact, don’t stare
  4. Speak calmly, confidently, and slowly
  5. Never threaten the patient, either verbally or physically
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10
Q

Anything that dampens or obscures the true meaning of the message

A

Noise

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11
Q

Two types of questions

A
  1. Open-ended
  2. Close-ended
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12
Q

Encourage the patient to talk more or provide more information

A

Facilitation

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13
Q

Do not speak

A

Pause

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14
Q

Restating a patient’s statement made to you to confirm your understanding

A

Reflection

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15
Q

Be sensitive to the patient’s feeling and thoughts

A

Empathy

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16
Q

Ask the patient to explain what they meant by an answer

A

Clarification

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17
Q

Make the patient who is in denial or in a mental state of shock focus on urgent and life-critical issues

A

Confrontation

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18
Q

Restate the patient’s complaint to confirm your understanding

A

Interpretation

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19
Q

Provide factual information to support a conversation

A

Explanation

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20
Q

Provide the patient with an overview of the conversation and the steps you will take

A

Summary

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21
Q

10 Golden Rules to help calm and reassure your patient and provide a therapeutic rapport

A
  1. Make and keep eye contact with the patient
  2. Provide your name and use the patient’s proper name
  3. Tell the patient the truth
  4. Use language that the patient can understand
  5. Be careful what you say about the patient to others
  6. Be aware of your body language
  7. Always speak slowly, clearly, and distinctly
  8. If the patient is hard of hearing, face the person so that they can read your lips
  9. Allow time for the patient to answer or respond to questions
  10. Act and speak in a calm, confident manner
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22
Q

The ability to understand and manage your own emotions and properly respond to others’ emotions

A

Emotional intelligence

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23
Q

5 attributes of emotional intelligence

A
  1. Self-awareness
  2. Self-regulation
  3. Motivation
  4. Empathy
  5. Social skills
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24
Q

The ability to recognize your own emotions and how they affect your thoughts and behavior

A

Self-awareness

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25
The ability to control impulsive emotions and behaviors and to manage emotions in positive ways
Self-regulation
26
The ability to motivate yourself and others in a positive direction, often deferring short-term rewards for long-term success
Motivation
27
The ability to understand the concerns, emotions, and needs of others by picking up on communication and social cues and clues
Empathy
28
The ability to develop and maintain positive rapport and relationships through effective communications
Social skills
29
Purposely focus your attention on the current moment, without blame and judgment for yourself or others
Mindfullness
30
Behavioral change stairway model
1. Employ active listening 2. Display empathy 3. Build a rapport 4. Exert influence
31
Never attribute ___ to old age
Altered mental status
32
Any communications where disruption will result in the failure of the task at hand
Mission-critical communications
33
The picture individuals have in their head of "what's going on"
Mental model
34
For any team to work effectively together, all members must share a ___
Mental model
35
The goal of mission-critical communications
An efficient, effective, and error-free transfer of the mental model
36
What questions need to be answered for an individual or team to build a mental model?
1. What is the focused priority for the patient? 2. What is the history of prior care? 3. What is the patient's current state? 4. What are the patient's immediate needs?
37
The transfer of pertinent patient information and the responsibility for the patient's care
Patient care handover or handoff
38
Giving the handover report
1. Initiate eye contact 2. Manage the environment 3. Ensure the ABCs 4. Provide a structured report 5. Provide documentation
39
SBAR
Situation Background Assessment Recap/Rx
40
SBAT
Situation Background Assessment Treatment
41
Receiving the handover report
1. Maintain eye contact 2. Manage the environment 3. Ensure understanding 4. Summarize 5. Gather supplementary patient documentation
42
Legal document used to record all aspects of the care your patient received, from initial dispatch to arrival at the hospital
Patient care report
43
Another term for the patient care report
Pre-hospital care report
44
Usually you will finish the PCR after ___
You have transferred care of the patient to an ED staff member
45
Two types of PCRs
Written Electronic (ePCRs)
46
The minimum data set for NEMSIS
Both narrative components and check boxes
47
PCR functions
1. Transfer of info and continuity of care 2. Compliance and legal documentation 3. Admin info 4. Reimbursement 5. Education 6. Data collection for quality improvement and research
48
EMS documentation uses ___ time
Military
49
Two most common narrative formats for PCRs used in health care
CHART SOAP
50
CHART
Chief complaint/concern History Assessments (Rx) treatments Transport
51
SOAP
Subjective Objective Assessment Plan
52
This narrative format method's strength is that it groups the care and treatment into smaller, logical sections, which makes it easier to locate specific assessments or care without reading the entire report
CHART
53
Weakness of CHART
Somewhat difficult to learn
54
For location in CHART ___
Be specific with the type of location, don't just say scene
55
Chief complaint vs chief concern
Complaint is what they are complaining of, but concern is the underlying problem that you are concerned about as an EMT
56
PCRs should include this information
1. Time of events 2. Assessment findings 3. Emergency medical care provided 4. Changes in the patient after treatment 5. Observations at the scene 6. Final patient disposition 7. Refusal of care 8. Staff person who continued care
57
Medicare and Medicaid payers will reimburse for ambulance transport only in the services are documented as being ___
Medically necessary
58
Means it would have been unsafe or impossible to transport the patient by any other means
Medically necessary
59
A system that allows EMS providers to access relevant health data, avoid unnecessary duplication of effort in data entry, and view patient outcomes related to hospital care
Health information exchange
60
HIE
Health information exchange
61
Most HIEs follow the ___ framework to improve patient care by giving health care providers rapid and universal access to accurate patient medical information
SAFR
62
SAFR
Search Alert File Reconcile
63
MCI
Mass casualty incident
64
Any radio hardware containing a transmitter and receiver that is located in a fixed place
Base station
65
As assigned frequency used to carry voice and/or data communications
Channel
66
Used for specific point-to-point contact
Dedicated line
67
Dedicated line is also know as a ___
Hotline
68
A special base station radio that receives messages and signals on one frequency and then automatically retransmits them on a second frequency
Repeater
69
Electronic signals are converted into coded, audible signals
Telemetry
70
A radio receiver that searches or scans across several frequencies, stops whenever it receives a radio broadcast on that frequency, and continues once the message is complete
Scanner

Emergency Medical Technician (100 decks)

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