©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. 13 Communication and Documentation Therapeutic Communication P306Personal Space p307 Open ended Question p310Closed ended Question p310 Incident Command System p312Portable Radio 313 Mobile Radio p313Narrative p318 Pre Hospital Care Report p316 Disposition p318 Objective p319Subjective p319 Define the following Terms:

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. OBJECTIVES DIRECTORY Objectives for this chapter can be referenced on pages 304 and 305 of your textbook.

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. TOPICS Communicating with Your Patient Communicating Patient Information to Other Providers Documentation

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. INTRODUCTION Communication –Patients –Other providers Documentation

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Dispatch –You are called to a holiday party for a patient who has passed out –You find the patient sitting on the carpet, leaning against the couch –She appears to be about 20 years old –12 nervous family members are standing around the patient THE CALL

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Communicating with Your Patient

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Accurate and Efficient Communication Minimum of noise Adequate lighting Privacy Patient’s level No intrusion into personal space Minimum of interruptions

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Active listening Barriers to communication Procedures Body language Accurate and Efficient Communication

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Patient Interview Techniques Open-ended questions –“What made you call for an ambulance tonight?” Closed-ended questions –“Okay, you told me about your chest pain. Do you feel pain anywhere else?” Pitfalls

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Communicating Patient Information to Other Providers

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed.

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed.

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Portable radios Mobile radios Base station radios Radio Communication

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Radio Communication General rules –Speak slowly and clearly –Hold microphone 4 inches from your mouth –Only speak when necessary –Listen before transmitting –Do not transmit names or confidential information –Speak professionally –Ensure your batteries are charged –Follow local procedure and protocol

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Special Communication Situations Challenged patients –Take your time –Ask the family how to communicate with patient –Do not assume reduced intelligence –Do not shout

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Special Communication Situations Deafness; blindness Mental impairment Differentiate AMS from normal status

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Patient seems alert and oriented You complete primary assessment and history Patient does not appear to want to talk to you THE RESPONSE

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Documentation

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed.

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Documentation Prehospital care report (PCR) Continuity of care Photo: Courtesy of the Regional Emergency Medical Organization, Albany, New York

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Components of the Prehospital Care Report Run data Patient data Narrative

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Components of the Prehospital Care Report Patient refusal –Facts to document Advised the patient that further care and transport is warranted Advised of the risks of refusing Steps you took to convince patient to accept care

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Components of the Prehospital Care Report Patient refusal –Facts to document Advised patient and/or family to call back if needed Encouraged patient to seek care elsewhere Took steps to ensure that someone remained with the patient continued on next slide

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Components of the Prehospital Care Report (cont.) PCR is a legal document –Objective documentation –Subjective documentation –Controversial statements

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Special Reporting Situations Abuse Assault Gunshot wounds Sexual assault Infectious disease Photo: © Edward T. Dickinson, MD

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. Patient remains stable You complete vital signs, a history, and a physical examination EMS arrives, and you prepare for transfer of care TRANSITION

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. REVIEW Define the following terms: –Therapeutic communication –Personal space –Barriers to communication –Open-ended question –Closed-ended question (direct question) –Portable radio –Mobile radio –Base station radio

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. REVIEW Define the following terms: –PCR –Continuity of care –Run data –Patient data –Narrative –Disposition –Objective –Subjective

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. STOP, REVIEW, REMEMBER The type of communication used to help a patient and calmly reassure him is referred to as _____ communication. a.therapeutic b.open-ended c.close-ended d.a barrier to

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. STOP, REVIEW, REMEMBER When starting a patient interview, what type of question is best to ask? a.Open-ended question b.Closed-ended question c.Therapeutic communication d.Efficient communication

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. STOP, REVIEW, REMEMBER Patients with hearing difficulties will often be able to communicate by seeing your _____ as you speak to them. a.eyes b.mouth c.tongue d.facial contours

©2014 Pearson Education, Inc. EMR Complete: A Worktext, 2 nd Ed. REVIEW Discussion 1.Differentiate between objective and subjective documentation. 2.Discuss the data elements of a PCR. 3.List some special reporting situations. 4.Discuss the general rules for radio use.