Medical Communications

Objectives List the two types of medical communications

List the essential content that should be included in all verbal communications, using the acronym SAILER

List the Components for the following methods used to complete a PCR: SOAP CHEATED

List the characteristics of good report writing using the acronym FACTUAL-OEC

Describe and demonstrate how to correct an error on a written report

List two criteria that must be documented on a patient refusal

List four injuries or crimes that a mandated reporter must report to authorities

Demonstrate how to complete a sample patient care report

Demonstrate how to provide an oral report

Types of Medical Communication Oral

Talking to patients Radio Walkie Talkies

Written forms

Oral Sailer Sex of patient Age of patient Incident/chief complaint Location Equipment needed Resources needed/extra patrollers

Incident Report Form Picture in book (pg 273) Patient Care report- a report that documents a

patients complaints and past medical history, plus a chronological account of the examination and treatment of the patient; it is a legal document

Forms cont. Subjective- chief complaint, history of present

illness, past medical history Objective- findings from physical exam and scene

size up Assessment- your general impression of what the

problem is Plan- aspects of treatment rendered to patient

Still forms… Chief complaint History-SAMPLE history Examination- physical exam Assessment- general impression of patient Tall aspects of treatment rendered (includes good

Samaritans) Evaluation-changes in the patient’s condition over time Disposition- did the patient refuse treatment? Was

patient transported to higher care?

FACTUAL-OEC Facts Accurate Complete Terms Unbiased Avoid slang Legible/legal

Organized Error free Checked