Emergency Medical Response Communication and Documentation

Emergency Medical Response

Communication andDocumentation


You Are the Emergency Medical Responder

As the closest responders in the area, your police unit is called to the scene where an elderly woman has collapsed in front of her home. When you arrive, a neighbor tells you that the woman suddenly collapsed and tripped on the concrete step in the walkway in front of her home. She is now conscious but a little dazed, and you find that she is also very frightened and apprehensive.

Lesson 11: Communication and Documentation


Components of Radio Communication for EMS

Base station – hub of communication Mobile radios and data terminals in EMR

vehicles Portable radios – handheld Repeaters- boost the range of portable

radios

Use “clear text” when talking on the radio


Communicating within theEmergency Communications

System Communications Center (dispatch)

9-1-1 call center Point of contact between public and

responders All conversations are recorded

Medical Control Orders repeated word for word

Medical Personnel Identify yourself as an EMR


Communicating within theEmergency Communications

System Receiving Facility Hospital

Who you are How many patients arriving Patient characteristics Immediate history Care provided and patients response ETA

Mobile Phone Cover longer distances than radio, superior sound

quality, direct communication between parties


Interpersonal Communication

Show empathy: be understanding and culturally sensitive to the thoughts, feelings and experiences of another person

Create positive relationships: Introduce yourself and team members Provide information about your role Eye level Listen


Activity

You arrive at the home of an elderly couple in response to a 9-1-1 call for assistance. The couple’s daughter called because her father, who is bedridden due to a stroke, was having difficulty breathing. The daughter is providing the information because the elderly couple speaks very little English.


Documentation

Established by state regulations Documenting care is as important as

providing care The record is a legal document If you are called to court, the

documentation supports your action(s) Quality assurance practices Final step in providing care, accurate &

complete

If it’s not written down, it didn’t happen!


Functions of the Prehospital Care Report (PCR)

Primary function: ensures high-quality care Other functions:

Legal document Educational and research tool Administrative tool –

billing/reimbursment Confidentiality – falls within HIPAA Refusal of treatment Falsification is a serious offence


Prehospital Care Report Sample

Page 207


Sections of the Prehospital Care Report

1. Run data 2. Patient data 3. Check boxes 4. Patient narrative Minimum data set

Patient information gathered by EMR Administrative information



1. Run data - administrative information Time of incident Arrival/departure of EMS at scene ETA of EMS to receiving facility/transfer of care EMS unit number EMS crew members and certifications Address of incident



2. Patient data – patient information Legal name Age Gender Birth date Home address Billing/insurance information Address of place of incident Any care provided before EMS arrival



3. Check boxes Vital signs Chief complaint LOC Appearance Respiration rate



4. Patient narrative open ended section for a written description

SAMPLE history Chief complaint MOI/NOI Description of what happened? Own words


You Are the Emergency Responder

As you assess the elderly patient, you learn that her chief complaint is that she “blacked out” momentarily and fell. The patient is afraid that she has broken her hip. She has pain in her pelvis and is unable to move her left leg. You give a verbal update to the EMS personnel who have just arrived to take over medical care and transport the patient. Why is it important for communication to brief and concise? What are some examples of effective interpersonal communication? Why is it important to thoroughly document your call, observations and actions?

Documents

Emergency Medical Response Communication and Documentation