EMS Communication & Documentation: Therapeutic Communication & System Documentation, Schemes and Mind Maps of Communication

Download EMS Communication & Documentation: Therapeutic Communication & System Documentation and more Schemes and Mind Maps Communication in PDF only on Docsity! Student Notes Chapter 4: Communications and Documentation 1 Chapter 4 Communications and Documentation Unit Summary After students complete this chapter presentation and the related course work, they will have an understanding of therapeutic communication; means to effective communication with specialty patients such as children, geriatrics, and hearing and visually impaired patients; methods and procedures for effective communication; components of effective written reports, types of written reports, and ways to correct errors found within written reports; documentation of refusal of care; special reporting situations; use of medical terminology; communications systems and equipment; regulations and protocols governing radio communications; and communication with medical control and hospitals. National EMS Education Standard Competencies Preparatory Applies fundamental knowledge of the emergency medical services (EMS) system, safety/well-being of the emergency medical technician (EMT), medical/legal, and ethical issues to the provision of emergency care. Therapeutic Communication Principles of communicating with patients in a manner that achieves a positive relationship: • Interviewing techniques (pp 110–118) • Adjusting communication strategies for age, stage of development, patients with special needs, and differing cultures (pp 108–109, 113–117) • Verbal defusing strategies (p 111) • Family presence issues (p 112) EMS System Communication Communication needed to: • Call for resources (pp 131–132) • Transfer care of the patient (pp 117–118, 134) • Interact within the team structure (pp 131–132) • EMS communication system (pp 127–130) • Communication with other health care professionals (pp 117–118, 132–136) • Team communication and dynamics (pp 132–136) Documentation • Recording patient findings (pp 119–126) • Principles of medical documentation and report writing (pp 119–126) Medical Terminology Uses foundational anatomical and medical terms and abbreviations in written and oral communication with colleagues and other health care professionals. Student Notes Chapter 4: Communications and Documentation 2 Knowledge Objectives 1. Describe factors and strategies to consider for therapeutic communication with patients. (pp 107–118) 2. Discuss the techniques of effective verbal communication. (pp 110–118) 3. Explain the skills that should be used to communicate with family members, bystanders, people from other agencies, and hospital personnel. (pp 110, 112, 113, 115–118) 4. Understand special considerations in communicating with older people, children, hearing-impaired patients, visually impaired patients, and non-English-speaking patients. (pp 113–117) 5. Describe the use of written communication and documentation. (pp 119–126) 6. Identify the information required in a patient care report (PCR). (pp 119–123) 7. Explain the legal implications of the patient care report. (pp 119, 123–125) 8. Understand how to document refusal of care, including the legal implications. (pp 124–125) 9. Discuss state and/or local special reporting requirements, such as for gunshot wounds, dog bites, and abuse. (p 125) 10. Understand the basic principles of the various types of communications equipment used in EMS. (pp 127–130) 11. Describe the use of radio communications, including the proper methods of initiating and terminating a radio call. (pp 130–136) 12. 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 130–136) 13. Give the proper sequence of information to communicate in radio delivery of a patient report. (p 134) Skills Objectives 1. Demonstrate the techniques of successful cross-cultural communication. (pp 108–109) 2. Demonstrate completion of a patient care report. (pp 119–124) 3. Demonstrate how to make a simulated, concise radio transmission with dispatch. (pp 131–136) Lecture I. Introduction A. Communication is the transmission of information to another person, whether it is verbal or through body language (nonverbal). 1. Effective communication is an essential component of prehospital care. 2. It is necessary to achieve a positive relationship with patients and coworkers. B. Verbal communication skills are important for EMTs. 1. Enable you to gather information from the patient, family members, and bystanders 2. Make it possible for you to coordinate all the responders who are often present at the scene Student Notes Chapter 4: Communications and Documentation 5 b. Use it consciously and sparingly. c. Avoid touching the patient’s torso, chest, or face simply as a means of communication, because these areas are often viewed as intimate. 6. Interview techniques to avoid a. Providing false assurance or reassurance b. Giving unsolicited advice c. Asking leading or biased questions d. Talking too much e. Interrupting f. Using “why” questions g. Using authoritative language h. Speaking in professional jargon 7. Hostile patients a. Patients can become hostile toward EMS providers. b. Defuse these potentially escalating circumstances by staying calm. c. Talk openly and honestly to the patient. d. Always consider the safety of the scene and call for law enforcement backup when necessary. e. Never threaten a patient. 8. Presence of family, friends, and bystanders a. They may be valuable during the patient interview process. b. Be sure to allow the patient to answer if he or she is able to and wants to, even if well-meaning family members attempt to answer for them. c. Do not be afraid to ask others to step aside for a moment while you talk to the patient. d. You may need to decide if having family and friends nearby will make the patient more or less anxious. 9. Golden Rules to help calm and reassure a patient a. Make and keep eye contact at all times. b. Provide your name, and use the patient’s proper name. c. Tell the patient the truth. d. Use language the patient can understand. e. Be careful what you say about the patient to others. f. Be aware of your body language. g. Speak slowly, clearly, distinctly. h. For the hearing-impaired patient, face the patient so he or she can read your lips. i. Allow the patient time to answer or respond. j. Act and speak in a calm, confident manner. H. Communicating with older patients 1. Identify yourself. 2. Be aware of how you present yourself. 3. Look directly at the patient. 4. Speak slowly and distinctly, not unnecessarily loud. 5. Explain what you are going to do before you do it. Student Notes Chapter 4: Communications and Documentation 6 6. Listen to the answer the patient gives you. 7. Show the patient respect. 8. Do not talk about patient in front of him or her. 9. Be patient! 10. Older patients: a. Often do not feel much pain b. May not be fully aware of important changes in their body systems c. Therefore, you must be especially vigilant for objective changes. 11. When possible, give the patient time to pack a few personal items before leaving for the hospital. 12. Locate any hearing aids, glasses, and dentures before departure. I. Communicating with children 1. An emergency situation frightens anyone. 2. Fear is most obvious and severe in children. 3. Children may be frightened by: a. Your uniform b. The ambulance c. A crowd of people gathered around them 4. Let a child keep a favorite toy, doll, or security blanket. 5. If possible, have a family member or friend nearby. a. If practical, let the parent or guardian hold the child during evaluation and treatment. 6. Be honest. Children easily see through lies or deception. 7. Tell the child ahead of time if something will hurt. 8. Respect the child’s modesty. 9. Speak in a professional, friendly way. 10. Maintain eye contact. 11. Position yourself down at the child’s level. a. Do not tower over a child. J. Communicating with hearing-impaired patients 1. Most people with hearing impairments have normal intelligence and are not embarrassed by their disability. 2. Position yourself so that the patient can see your lips. 3. Hearing aids a. Be careful that they are not lost during an accident or fall. b. They may be forgotten if the patient is confused. c. Ask the family about use of a hearing aid. 4. Steps to take to efficiently communicate with patients who are hearing impaired: a. Have paper and pen available. Student Notes Chapter 4: Communications and Documentation 7 b. If the patient can read lips, face patient and speak slowly and distinctly. c. Never shout. d. Listen carefully, ask short questions, and give short answers. e. Learn some simple phrases in sign language. i. For example, it can be useful to know the signs for “sick,” “hurt,” and “help.” K. Communicating with visually impaired patients 1. Ask the patient if he or she can see at all. a. Visually impaired patients are not necessarily completely blind. b. Expect your patient to have normal intelligence. 2. Explain everything that you are doing as you are doing it. 3. Stay in physical contact with the patient as you begin your care. 4. If the patient can walk to the ambulance, place his or her hand on your arm. 5. Transport mobility aids such as a cane with the patient to the hospital. 6. Guide dogs a. Easily identified by their special harnesses b. If possible, transport the dog with the patient. i. This alleviates stress for both the patient and the dog. Guide dogs are trained not to leave their masters. c. Otherwise, arrange for care of the dog. A conscious patient can tell you about the dog and give instructions for its care. L. Communicating with non-English-speaking patients 1. You must obtain a medical history even though the patient does not speak English. You cannot skip this step. 2. Find out if patient knows a few English words or phrases. 3. Use short, simple questions. 4. Point to parts of the body. 5. Have a family member or friend interpret. 6. Consider learning some common phrases in another language that is used in your area. 7. Pocket cards that show the pronunciation of terms are available. M. Communicating with other health care professionals 1. Your reporting responsibilities do not end when you arrive at the hospital. a. Effective communication between EMS providers and other health care professionals in the receiving facility is essential to efficient, effective, and appropriate patient care. 2. You must give an oral report to a hospital staff member. a. That staff member must have at least your level of training 3. Oral report components: a. Opening information i. Name, chief complaint, illness b. Detailed information i. Not provided during radio report Student Notes Chapter 4: Communications and Documentation 10 a. Gunshot wounds b. Dog bites c. Some infectious diseases d. Suspected physical or sexual abuse e. Mass-casualty incident (MCI) H. Medical terminology 1. The reason for using medical terminology is that all medical providers understand it. 2. Medical personnel around the globe speak the same language: Latin. 3. Taking a medical terminology course can be helpful. IV. Communications Systems and Equipment A. Base station radios 1. A base station is any radio hardware containing a transmitter and receiver that is located in a fixed place. 2. A two-way radio consists of transmitter and receiver. B. Mobile and portable radios 1. A mobile radio is installed in a vehicle. 2. Mobile radios are used in the ambulance to communicate with: a. The dispatcher b. Medical control 3. An ambulance often has more than one mobile radio. 4. Portable radios are hand-held devices. 5. Portable radios are essential at the scene of an MCI. 6. When away from the ambulance, a portable radio is helpful to communicate with: a. Dispatch b. Another unit c. Medical control C. Repeater-based systems 1. A repeater is a special base station radio a. Receives messages and signals on one frequency b. Automatically retransmits them on a second frequency c. Provides outstanding EMS communications D. Digital equipment 1. Voice is not the only EMS communication 2. Some EMS systems also transmit: a. Electrocardiogram from unit to hospital b. Telemetry allows electronic signals to be converted into coded, audible signals. 3. Digital signals are also used in some kinds of paging and tone-alerting systems. Student Notes Chapter 4: Communications and Documentation 11 E. Cellular/satellite telephones 1. EMTs often communicate with receiving facilities by cellular telephone. a. A cellular telephone is simply a low-power portable radio. 2. Satellite phones (satphones) are another option. 3. Conversations can be easily overheard on scanners. Always be careful to respect patient privacy and speak in a professional manner whenever you use any form of EMS communications system. F. Other communications equipment 1. Ambulances usually have an external public address system. 2. Two-way radio hardware may operate in simplex or duplex mode. a. Simplex is push to talk, release to listen. b. Duplex is simultaneous talk–listen. 3. MED channels are reserved for EMS use. 4. Trunking, or 800-MHz, systems use the latest technology to allow greater traffic. 5. Mobile data terminals (MDTs) inside ambulance a. Receive data directly from dispatch center b. Allow for expanded communication capabilities i. For example, maps V. Radio Communications A. The Federal Communications Commission (FCC) regulates all radio operations in the United States. 1. The FCC has five principal EMS-related responsibilities. a. Allocating specific radio frequencies for use by EMS providers b. Licensing base stations and assigning appropriate radio call signs for those stations c. Establishing licensing standards and operating specifications for radio equipment used by EMS providers d. Establishing limitations for transmitter power output e. Monitoring radio operations 2. The FCC’s rules and regulations section (part 90, subpart C) deals with EMS communications issues. B. Responding to the scene 1. The dispatcher receives the first call to 9-1-1. 2. Dispatcher has several important responsibilities. a. Properly screen and assign priority to each call (according to predetermined protocols) b. Select and alert the appropriate EMS response unit(s) c. Dispatch and direct EMS response unit(s) to the correct location d. Coordinate EMS response unit(s) with other public safety services until the incident is over e. Provide emergency medical instructions to the telephone caller 3. Dispatcher assigns the appropriate EMS response unit(s) based on several criteria. a. Nature and severity of the problem b. Anticipated response time to the scene Student Notes Chapter 4: Communications and Documentation 12 c. Level of training of available EMS response unit(s) d. The need for additional support 4. Dispatcher should give the responding unit(s) the following information: a. Nature and severity of the injury, illness, or incident b. Exact location of the incident c. Number of patients involved in the incident d. Responses by other agencies e. Special directions or advisories (adverse road or traffic conditions or severe weather reports) f. Time unit(s) are dispatched 5. EMTs report any problems that took place during a run to the dispatcher. 6. EMTs inform the dispatcher upon arrival at the scene. a. Arrival report should include any obvious details observed during scene size-up. b. Radio communications must be brief and easily understood. c. Speaking in plain English is best. d. Some areas may use 10 codes. C. Communicating with medical control and hospitals 1. Principal reason for radio communication is to facilitate communication between you and medical control (and the hospital). 2. Medical control may be located at the receiving hospital, another facility, or sometimes even in another city or state. 3. Consulting with medical control serves several purposes. a. Notifies the hospital of an incoming patient b. Provides an opportunity to request advice or orders from medical control c. Advises the hospital of special situations 4. Plan and organize your radio communication before you transmit. 5. How to give the patient report a. Follow the standard format established by your EMS system. b. Include seven elements: i. Your unit identification and level of services ii. The receiving hospital and your estimated time of arrival (ETA) iii. The patient’s age and gender iv. The patient’s chief complaint or your perception of the problem and its severity v. A brief history of the patient’s current problem vi. A brief report of physical findings vii. A brief summary of the care given and any patient response c. Report all patient information in an objective, accurate, and professional manner. d. Remember, people with scanners may be listening. 6. The role of medical control a. Medical control is either off-line (indirect) or online (direct). b. Depending on how the protocols are written, you may need to call medical control for direct orders (permission) to conduct certain tasks, including: Student Notes Chapter 4: Communications and Documentation 15 Post-Lecture Unit Assessment 1. ___________ 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. 2. What are five factors and strategies to consider during communication? 3. When you consider your own cultural values as more important when you are interacting with people of a different culture, you are displaying _______________. 4. What are four things that the EMT should do when interviewing an older patient? 5. What type of radio is installed in the ambulance? 6. What is the function of a repeater? 7. What are the functions of the prehospital care report? 8. Name four pieces of information that need to be included in the narrative section of the patient care report. 9. What is the agency that regulates radio operations in the United States? 10. What seven items should be included in the radio report given about a patient? 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