Introduction to Emergency Medical Care 1

Introduction to Emergency Medical Care 1
Advance Preparation Prepare examples of communication equipment. Plan a tour of a local communications/dispatch center. Invite an EMS dispatcher.

OBJECTIVES 17.1 Define key terms introduced in this chapter. Slides 13–15, 30– Describe the role of communication technology in EMS systems. Slide Describe various types of communication devices and equipment used in EMS system communication. Slides 14–15 continued

OBJECTIVES 17.4 Explain the role of the Federal Communications Commission as it relates to EMS system communication. Slide Discuss how to communicate effectively by radio with dispatch and hospital personnel. Slides 17–22 continued

OBJECTIVES 17.6 Provide a thorough, organized, concise report of pertinent patient information when giving a radio report or requesting orders. Slides 25– Explain the importance of asking for information to be repeated for confirmation and clarification. Slide 28 continued

OBJECTIVES 17.8 Deliver an organized, complete, and concise report of pertinent patient information when giving a verbal report to receiving hospital personnel. Slides 30– Demonstrate principles and techniques of effective verbal and nonverbal interpersonal communication. Slides 36–38 continued

OBJECTIVES 17.10 Adapt communication principles for effective interaction with patients of various ages and cultures. Slide Complete a prehospital care report in the format or formats required by your service. Slides 42– Understand legal issues and special situations associated with documentation. Slides 56–57, 60–61

MULTIMEDIA Slide 32 Effective Communication Video
Slide 40 Alternate Methods of Communication With Children Video Slide 54 Understanding Cultural Perspectives Video These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

Radio procedures used at various stages of the EMS call
Delivery and format of a radio report to the hospital Delivery and format of a verbal hand-off report to the hospital continued

Communication skills used when interacting with the patient
Communication skills used when interacting with other members of the health care team Communication skills used when interacting with the patient Components and procedures for the written prehospital care report continued

Legal aspects and benefits of documentation
Documentation concerns in patient refusal

Topics Communication Systems and Radio Communication The Verbal Report
Interpersonal Communication Prehospital Care Report Special Documentation Issues Planning Your Time: Plan 85 minutes for this chapter. Communications Systems and Radio Communication (15 minutes) The Verbal Report (15 minutes) Interpersonal Communication (20 minutes) Prehospital Care Report (20 minutes) Special Documentation Issues (15 minutes) Note: The total teaching time recommended is only a guideline.

Communication Systems and Radio Communication
Teaching Time: 15 minutes Teaching Tips: Take a field trip. Visit a local EMS communications center. Review components of EMS communications there. Invite an EMS dispatcher to class. Share the insights of an experienced professional communicator. Have actual radio systems on hand to demonstrate. Listen in. Scan local EMS frequencies and hear actual EMS communications.

Communication Systems
EMS uses various communication systems: Radios One-way pagers Cell phones Traditional telephones (landlines) Point to Emphasize: Traditional EMS radio systems take a variety of forms. Most systems have common components that are readily identifiable. Talking Points: Radios are the most common communication system, as they are versatile and inexpensive, allow two-way communication, don’t rely on commercial cell towers, and their transmissions are frequently recorded. Cell phones transmit through the air to cell towers, they can reach greater distances, and digital transmissions are very clear (although commercial cell towers may not yet be accessible in some rural areas).

Radio Systems EMS radio systems consist of: Base station Mobile radios
Portable radios Repeaters Microwave transmissions Digital radio signals Talking Points: Base stations are fixed locations such as dispatch centers or hospitals. Mobile radios are mounted in vehicles. Portable radios are handheld and battery-powered. Repeaters receive a radio signal and rebroadcast it over another frequency at a much higher power to reach long distances. Microwave transmission is now used in some areas. Digital radio transmissions can be sent with the simple push of a button, and are useful for status changes such as “call received,” “en route,” “on scene,” reducing radio traffic. Discussion Topic: Describe the components of an EMS radio system. Class Activity: Visit a local EMS communications center. Identify radio components; discuss radio communication techniques.

Repeaters Class Activity: Invite a local communications supervisor or dispatch to discuss the local communications system.

Radio Communication Regulation
Regulated by the Federal Communications Commission (FCC) Assign and license designated radio frequencies Establish rules regarding appropriate language Monitor radio traffic Point to Emphasize: The Federal Communications Commission (FCC) regulates radio usage in EMS. Discussion Topic: Describe the federal and local regulation of EMS radio communication.

Principles of Radio Communication
Radio on and volume adjusted properly Reduce background noise Ensure frequency is clear before starting Press PTT (press to talk) button on radio; wait 1 second before speaking Talking Points: Wait at least 1 second after pushing the PTT button before beginning your transmission; this will prevent your first word from being cut off. This is especially important for systems using a repeater. continued

Lips about 2–3 inches from microphone Use unit names or numbers Call unit’s attention first; wait for “go ahead” Unit may say “stand by” until ready Talking Points: Do not speak directly into the microphone, as the air from your mouth will be heard as static. Direct your voice across the microphone. Avoid using people’s names. Knowledge Application: Scan local EMS frequencies and listen to actual communications. Discuss positive and negative examples. continued

Speak slowly and clearly Keep it brief Use plain English, avoid codes Avoid unnecessary words (“be advised” or “please”) Talking Points: Codes are frequently different between services, and may be misunderstood. Courtesy is implied: avoid niceties and filler words that only prolong your transmission. continued

If number might be unclear, say number and repeat individual digits Never use patient’s name over radio Never use profanities or slander Use objective, impartial statements Talking Points: “Unit 15” may be heard as “Unit 50”; avoid miscommunication by saying “Unit 15, one-five.” Civilians with scanners may be listening to radio transmissions, so you should never use a patient’s name or other identifying information because HIPAA laws apply. Refrain from offering an opinion, give “just the facts.” continued

Use “we” instead of “I” “Affirmative” and “negative” preferred over “yes” and “no” Give assessment information about patient; avoid offering diagnosis Talking Points: You are part of a team, and will rarely work alone, so “we” is more appropriate than “I.” The words “yes” and “no” are often difficult to distinguish in a radio transmission. Again, just give the facts. continued

After transmitting, say “Over” Avoid slang or unauthorized abbreviations Use EMS frequencies for authorized EMS communication only Talking Points: Avoid pauses in your transmission; others may think you are done and begin their own transmission. When finished, say “over” to officially end your transmission. Do not use the radio to say hello to a coworker in another unit, or any other personal business; these frequencies are for EMS communications only. Discussion Topic: Describe the essential components of communication between provider and EMS dispatcher.

Other Radio Procedures
If two units transmit simultaneously, only one will be heard by listeners Dispatch often confirms receipt of transmission by repeating part of it back Dispatch may end transmission with time for documentation Point to Emphasize: Most radio communication in EMS takes place between field personnel and dispatch. Common processes make communication more efficient. Talking Points: When two units transmit simultaneously, the one heard is often closest to dispatch or the one with the more powerful radio. The confirmation by dispatch will be your indication that dispatch, as opposed to another unit, heard you. continued

Other Radio Procedures
Carry portable radio whenever you leave unit Radios need proper care and maintenance Talking Points: Proper care and maintenance includes checking that all radios are functioning before the start of your shift, ensuring that portable radios are sufficiently charged. The portable radio may be your lifeline in the event of an emergency. Knowledge Application: Make radio communication an ongoing lesson. Require radio communication and patient reports for any mock scenario.

Medical Radio Reports Report must be given to destination hospital so it can prepare for arrival Usually done by radio Structured to present only most important information Speak clearly and slowly Point to Emphasize: The medical radio report is structured to present pertinent facts about the patient without telling more detail than necessary. Talking Points: The hospital may need to prepare a certain room, call a specialist, or have specific equipment ready for your arrival. Some providers and hospitals prefer medical reports be given by phone to protect patient’s privacy. Be brief; excessive details take up everyone's time and tie up the radio frequency. Paint a quick verbal picture. If your patient is critical, prepare your words, take a deep breath, stay calm, speak slowly and deliberately. Class Activity: Invite a local communications supervisor or dispatch to discuss the local communications system.

Parts of Medical Report
Unit identification and level of provider Estimated time of arrival (ETA) Patient’s age and sex Chief complaint Brief, pertinent history of present illness/injury Major past illnesses Talking Points: Remember, be brief. Give only pertinent information that the hospital can use to prepare for your arrival. Detailing all the complaints or the patient’s entire medical history is not necessary; this will be given in a face-to-face verbal report. continued

Parts of Medical Report
Mental status Baseline vital signs Pertinent findings of physical exam Emergency care given Response to medical care Medical direction if required, or if questions Talking Points: Give only physical exam findings that are pertinent to the patient’s condition (swollen feet would be pertinent in a cardiac patient, but not in a hand laceration patient); certain information should be saved for the face-to-face verbal report. Discussion Topic: Describe an EMS radio report. What elements must be included? Knowledge Application: Use actual radios (or toy radios) and require students to give real-time medical radio reports. Critique and discuss. Critical Thinking: What potential confidentiality concerns arise out of communicating patient information over the radio?

Communicating With Medical Control
Give information clearly and accurately After receiving order or denial for medication or procedure, repeat back word for word If order unclear, ask physician to repeat If order seems inappropriate, question physician Talking Points: Communicating with medical control is particularly important. You will be speaking to a physician. Medical control will confirm or deny your request by the quality of your report. Speak confidently and professionally. Remember, radio transmissions are recorded, so requests for medical control orders should be made by radio.

The Verbal Report Teaching Time: 15 minutes
Teaching Tips: Practice makes perfect. Use mock scenarios and practice verbal reports. Make verbal reports (and radio reports) an ongoing lesson in class. Require reports to be given after any scenario. Offer constructive criticism. Don’t allow poor reports. Correct and require improved performance.

Detailed Verbal Report
Given upon arrival at destination Introduce patient by name Give complete and detailed report Points to Emphasize: The first information given to hospital personnel usually will be the verbal report. A verbal report will summarize and enhance the prior radio report. Talking Points: The verbal report is given when turning over patient care at hospitals and other destinations. This is not the time to be brief; be detailed and specific. The person you give the verbal report to is likely not the same person you gave the radio report to. Discussion Topic: When would an EMT utilize a verbal report? Class Activity: Assign students the task of practicing five verbal reports at home. Have them make up scenarios and practice with a friend. Have them document self-critiques. Knowledge Application: Have students work in small groups. Provide each group with a scenario and have them prepare and deliver a verbal report. Critique and discuss. continued

Detailed Verbal Report
Elements of report Chief complaint History of present illness/injury Assessment findings, including pertinent negatives Treatment given and response Complete vital signs Point to Emphasize: A proper verbal report will include the chief complaint, any history that was not given previously, additional treatment given, and additional vital signs taken en route. Discussion Topic: Discuss the key components of an effective verbal report. Knowledge Application: Assign “written verbal reports.” Provide an in-class scenario and have students write up the components of their verbal report. Critical Thinking: This chapter discusses limiting verbal reports and being concise. What are the potential hazards of being too brief?

Effective Communication Video
Video Clip Effective Communication What is the goal of communication? Why is it necessary for a leader to be an effective communicator? Why should EMTs choose their words carefully? Describe ways for EMTs to communicate effectively with their superiors. Why is follow-up in communication an important task for an EMT? Click here to view a video on the subject of effective communication. Back to Directory

Interpersonal Communication
Teaching Time: 20 minutes Teaching Tips: Role play. Use scripted situations to simulate communication challenges. Discuss. Use nonverbal communication. Ask students to demonstrate nonverbal communication; discuss the results. Discuss improving communication in the context of the secondary assessment. Build on the lessons of previous chapters. Review how more information might improve the assessment. Discuss language choices. Relate this section to medical terminology. Discuss how plain language can aid therapeutic communication.

Team Communication EMT must communicate with others involved in patient’s care First responders Advanced EMTs, paramedics Home healthcare aides, family Speak candidly and respectfully Collect information about patient Point to Emphasize: Communication is an invaluable component of teamwork. Talking Points: EMTs need to communicate effectively with many types of people. Bystanders include family and witnesses. EMS personnel include your partner, crew members, supervisors, managers, medical directors. Public safety personnel include firefighters, police officers, security guards. Hospital staff include doctors, nurses, surgeons, administrators, clerks. Others to communicate with include utility workers, nursing home staff, teachers, school nurses, and others with an important role at a scene. You need to draw as much information as possible from other members of the team. You need information for a complete assessment, and must appropriately transfer care. Discussion Topic: Discuss the role of communication in teamwork.

Therapeutic Communication
Communication techniques learned by experience May be more difficult with those in crisis Everyone can improve communication skills Point to Emphasize: Communicating with patients who are in crisis can be difficult, but there are techniques to improve communication capabilities. Talking Points: Communication skills are naturally easy for some, more difficult for others. They can be difficult to learn, but they can be learned.

Communication Techniques
Use eye contact Shows interest, comfort, and respect Be aware of position and body language Face patient at eye level, arms down Talking Points: A patient may avoid eye contact due to cultural beliefs. In these cases, match your behavior to theirs. Standing above the patient with arms crossed (closed stance) conveys authority, not warmth and understanding. This stance may be necessary at times to gain control. Pay attention to the patient’s body language: a closed stance may indicate your failure to make the patient comfortable. Discussion Topic: How might personal space and body language impact communication? What are some steps that an EMT might take to improve these elements? Knowledge Application: Use a programmed patient and simulate assessment scenarios. Present barriers to communication (loud music, overly aggressive family, and the like). Have students develop communication strategies to overcome these problems. continued

Use appropriate language Ensure patient understands Be honest Dishonesty ruins confidence and rapport Talking Points: Do not use complex medical terms, and explain procedures before you perform them. If the patient asks a difficult question (“Am I having a heart attack?”), answer truthfully, but with care, compassion, and concern. Remember, you are their introduction to medical care, and distrust of you may lead to distrust of the care providers they meet later. Critical Thinking: You are treating a patient who has had a stroke. As a result of the stroke, the patient cannot speak. How might you still be able to communicate with this patient? continued

Use patient’s proper name Sign of respect, especially with older patients Listen Important to establish trust Talking Points: Use the patient’s last name unless she insists you call her by her first name. Never use condescending names like “honey” or “sweetie.” After asking a question, give the patient time to answer. Listen intently to the answer without interrupting. If the patient feels you are not paying attention, rapport will be lost. Discussion Topic: Describe five steps that improve interpersonal communication. Class Activity: Have a class discussion. Develop a list of positive communication traits based on students’ personal experience. Brainstorm and then prioritize the list. Knowledge Application: Create simulated assessments, but use students as patients. Have programmed providers use poor communication techniques; then discuss the impact on the assessment. continued

Special considerations Always be compassionate and respectful Mentally disabled Visual or hearing impaired Language barriers Pediatric patients Come down to their level Be truthful Point to Emphasize: Pediatric, elderly, and other special populations of patients may require the EMT to adapt communication practices. Talking Points: Adults with mental disabilities should be treated like adults. Speak slowly and clearly, and explain everything. Blind patients are not deaf: do not yell, explain your actions, ask before touching them, and do not physically lead them. Hearing impaired patients may communicate in writing; a basic knowledge of sign language would be beneficial. If you do not speak the patient’s language, use bilingual family members or bystanders, hospital translation services, telephone interpreter, etc. Your size may intimidate a child, kneel down to the child’s level and make eye contact. Children almost always feel comfortable with their parents; involve them when communicating with children. Be honest, children are sensitive to lies and deception. Distracting children with toys or allowing them to play with safe EMS equipment may be beneficial. Discussion Topic: Discuss how interpersonal communication with a child might be different from that with an adult.

Alternate Methods of Communication With Children Video
Video Clip Alternate Methods of Communication With Children How do children communicate through play? What are some alternate ways to communicate with children? What are some techniques that an EMT can use to help reduce a child’s fear? Click here to view a video on the subject of communicating with children. Back to Directory

Prehospital Care Report
Teaching Time: 20 minutes Teaching Tips: Make documentation routine (as it is in EMS). Require documentation of all simulated calls. Consider take-home assignments to complete documentation. Discuss the path of a PCR. Detail who might review it and how it might be used beyond the level of the EMT. Discuss the role of PCRs within a quality assurance system. Present a state PCR (handwritten or electronic). Discuss its components.

Prehospital Care Report (PCR)
Written documentation of everything that happened during call Several forms Handwritten Laptop Electronic tablet Web based Point to Emphasize: The prehospital care report serves as the record of the EMT’s interaction with the patient. The prehospital care report can take a variety of formats, from handwritten to electronic. Talking Points: Your state, region, or service may call it a run sheet, trip report, or other similar name. Some are still handwritten, most are computerized. Laptop versions are written on a portable laptop computer, electronic tablet types are small touch screen computers that use check boxes or translate handwriting into text, web based require logging in to a web site. Discussion Topic: Describe how patient care is documented in your area. What are the required components?

Functions of PCR Patient care record Documents findings and treatment
Conveys picture of scene Entered into patient’s permanent medical record Points to Emphasize: Besides being a record of patient interaction, the prehospital care report also serves as a legal document, provides information for administrative functions, aids education and research, and contributes to quality improvement. Talking Points: Your PCR documents everything you saw, found, and did. If it is not recorded in the PCR, it did not happen. It records the scene, and all that happened before arrival at the hospital. Remember, those that read your PCR did not see what you did; you need to “paint” a clear picture of what you saw. It should be completed before you leave the hospital, so the staff can reference it when caring for the patient. Class Activity: Present a scenario to the class. Discuss interactions and interventions. continued

Functions of PCR Legal document Can be subpoenaed and used as evidence
May help patient win a case May be used against you in case of negligence Talking Points: The PCR is a legally binding document, and is frequently used as evidence. You may also be called to testify that you wrote it. A PCR can be used to prove a patient was injured, assaulted, or abused. It can also be used to prove negligence. Court cases are often months or years later; therefore, the PCR will be your memory of the event, so record it accurately. Remember, legally, only what is recorded occurred. Therefore, if it is not written, it did not officially happen. Discussion Topic: Discuss the role of confidentiality with regard to patient documentation. Why does a PCR need to be strictly confidential? Critical Thinking: How might a properly documented PCR protect an EMT from liability? How might it defend an EMT in the event of a lawsuit? continued

Functions of PCR Administrative Demographic information
Insurance information Billing address Talking Points: If your service bills for service, the PCR is vitally important, as it contains all demographic information, including the patient’s address, date of birth, social security number, insurance information, and usually signature that confirms their agreement for financial responsibility. continued

Functions of PCR Education and research Clinical research Statistics
Continuing education Tracking EMT’s personal experience Talking Points: Researchers can access PCRs to collect data for research and compile statistics on injuries or EMS use. PCRs can be used as educational tools: unusual or uncommon patients and their PCRs can be presented as CE. Each treatment is recorded and attached to a provider or employee number, and these skills can be tracked and totaled. continued

Functions of PCR Quality improvement Routine call review
Ensures compliance to standards Can reveal providers deserving special recognition Can reveal opportunities for improvement Talking Points: Often called QI, QA (quality assurance), or CQI (continuous quality improvement). Random call review monitors adherence to policies, protocols, scope of practice, or other medical or operational standards. They can expose an outstanding outcome, or an area of weakness. Knowledge Application: Create class QA committees. Have students submit their routine documentation to their peers for review.

Elements of PCR Run data
Agency name, date, times, call number, unit personnel, certification levels, other information mandated by service Use official time given by dispatch so all times in report match Point to Emphasize: A prehospital care report consistently contains key elements, including the run data and patient information sections. Talking Points: There may be a difference of several minutes between the time displayed on your watch and the dispatch center’s official time. This time difference may seem insignificant but is actually very important in such areas as determining how long a patient has been in cardiac arrest, trends in patient condition, or measurement of system efficiency in response times. Discussion Topic: List and describe the essential elements of the “run data” section of a PCR. continued

Elements of PCR Patient information Name, address, phone number
Gender, age, date of birth Weight Race and/or ethnicity Billing and insurance information Discussion Topic: List and describe the essential elements of the “patient information” section of a PCR. Knowledge Application: Have students write prehospital care reports for simulated calls. Review and grade the documentation. continued

Elements of PCR Information gathered during call
General impression of patient Narrative summary of call Patient history and treatment as required by service Transport information

Elements of Narrative Summary
Objective information Observable, measurable, verifiable Subjective information Subject to interpretation or opinion (often reported by patient) Talking Points: Objective information: “3-inch laceration above the left eye” or “blood glucose level 128” or “history of hypertension.” Subjective information: “patient complaining of severe back pain” or “patient reports no loss of consciousness.” Avoid making your own subjective statements in your report: “Patient is experiencing an MI” is your opinion, not an official diagnosis. continued

Chief complaint Primary complaint, as stated by patient Best recorded as a direct quote Pertinent negatives Important negative findings Talking Points: The chief complaint is exactly that, the one primary thing the patient is complaining of. The presenting problem, or mechanism of injury (MVC, fall, broken leg) is not a chief complaint. An appropriate chief complaint would be “neck pain,” “difficulty breathing,” or “leg pain.” A direct quote is most accurate: “My leg hurts.” The lack of swollen feet in a respiratory patient is an important negative finding, and must be recorded. Knowledge Application: Practice narratives. While completing simulated calls, have students write brief narratives of the patient’s information. continued

Plain English and approved abbreviations Avoid codes and unofficial abbreviations Legible; correct spelling and grammar Information must be read easily and accurately PCR is a reflection of your care Appropriate medical terminology If it happened, record it Talking Points: Others reading your PCR may not be familiar with codes. Abbreviations are useful and will reduce the length of your chart and the time needed to complete it, but only common medical abbreviations should be used. Computerized PCRs eliminate legibility problems, but handwritten PCRs must be legible. A sloppy PCR with spelling or grammar errors may be seen as poor patient care. Your chart should sound like it was written by the trained professional you are. Use professional medical language: “laceration” instead of “cut”; “ecchymosis” instead of “bruise.” But do not try to use medical terms you are not familiar with. Remember the saying…“If it’s not written, you didn’t do it.” Class Activity: Present a scenario to the class. Discuss interactions and interventions. Have each student complete a PCR at home and return it at the next class. Have students exchange patient care reports and correct each other’s work. Discuss and critique.

Understanding Cultural Perspectives Video
Video Clip Understanding Cultural Perspectives Why is it necessary for an EMT to understand different cultural beliefs and values? Why should an EMT approach every patient as a unique individual? How can an EMT be sensitive to a patient’s beliefs about death and dying? How can a patient’s beliefs about medicines and nutrition influence the care that an EMT provides? Discuss ways in which an EMT can become more culturally competent. Click here to view a video on the subject of sensitivity to cultural diversity. Back to Directory

Special Documentation Issues
Teaching Time: 15 minutes Teaching Tips: Rigorously enforce confidentiality standards. Do not accept violations, even in routine class discussions. Use a class QA committee. Have students submit their routine documentation to their peers for review; critique documentation errors. Invite an attorney to class to discuss the role of confidentiality and proper documentation with regard to medical/legal situations.

Documentation Issues Confidentiality Refusals Covered by HIPAA
Accountability and security Refusals High liability Document all details in a “refusal of care” form Points to Emphasize: The prehospital care report itself and the information that it contains are strictly confidential. A properly documented patient care report is an essential component of patient refusal. Talking Points: To ensure accountability and security, put completed PCRs in lock boxes or other secure areas for safe keeping. For refusals, you must do a thorough assessment and document all findings in detail, including why the patient refused and what you recommended. Make sure to tell patients to call back if they feel worse. If the patient meets refusal criteria, have the patient as well as a witness (preferably family or police, not your partner) sign the refusal form. Consider a medical control consult, as well. Discussion Topic: Describe the necessary documentation elements with regard to a patient refusal. Class Activity: Have a mock trial. Choose a PCR from a simulation and accuse a student of wrongdoing. Can the student defend himself, based on the documentation? Knowledge Application: Have students write prehospital care reports for simulated calls. Review and grade the documentation. Use simulated PCRs during clinical experiences. Have students write simulated patient care reports for patients whom they have seen; then compare and contrast with the actual PCR. continued

Documentation Issues Falsification Correction of errors
Covering up errors Recording something you forgot to do Correction of errors Mistakes in documentation Additions Points to Emphasize: Falsification of a patient care report can occur by either commission or omission. In either case, a serious offense has taken place. Proper procedures must be followed to correct a patient care report. Talking Points: Although you may be the only witness, resist the temptation to cover up a patient care error by not documenting it or falsifying information. Omissions or misinformation could affect patient care, and will look worse when uncovered later. If you made a mistake, own up to it. If you forgot to do something, state why. Honesty is always best. Do not completely obscure mistakes on your chart. Draw a single line through them, and initial them. Additions may require an addendum. Discussion Topics: Explain the difference between errors of omission and errors of commission with regard to falsification of patient care reports. Describe the steps involved in correcting a patient care report. Class Activity: Require students to modify a PCR. Assign specific changes and have students complete these changes as a homework assignment. Knowledge Application: Create a student QA committee. Select random documentation from programmed patients and review the patient care report as a group. Discuss.

Think About It You respond to a call for an unconscious male. Upon arrival the patient is awake, alert, and walking away. He states he was just sleeping, and does not need or want treatment or transport. continued

Think About It Is this a patient?
Is a complete assessment and physical exam needed? How will you document this call? Should you obtain a formal patient refusal? Talking Points: A complete assessment and head-to-toe physical exam is probably not needed. The patient did not call EMS and appears to not need it. Your limited interaction can give much information for documentation: “The patient is awake and alert, and in no obvious distress; he has no complaints of pain, illness, or injury; there is no obvious trauma; patient moves all extremities well, and ambulates without assistance.” Your chart should at least include this brief assessment, along with the other details of the event. Local policy may require a refusal; if so, don’t forget a witness and a patient signature.

Special Situation Reports
Multiple casualty incidents Logistical problem for EMS Many patients Care and evaluation by several providers at different times and locations Talking Points: Many common rules do not apply in MCIs. Care is a unique situation, and documentation also differs. Typically most assessment and patient care is documented on a single triage tag that stays with the patient. Providers may add or change information as needed. The EMT who transports the patient to the hospital will use the triage tag to complete one comprehensive traditional PCR. continued

Special Situation Reports
Provider exposures Provider injuries Hazardous or unsafe scenes Referrals to social service agencies Reports of abuse Talking Points: These are a few situations that may require supplemental documentation. These forms are often specific to a local agency and not part of a PCR.

Chapter Review

Chapter Review Radio report should include unit ID and provider level; ETA; patient’s age and sex; chief complaint; pertinent HPI; major past illnesses; mental status; baseline vital signs; physical exam findings; emergency care given and response; request to contact medical direction. continued

Chapter Review PCR should include patient’s name, address, date of birth, age, and sex; billing and insurance information; nature of call; MOI; location patient was found; treatment given before EMT arrival. continued

Chapter Review PCR may be a legal document in a court proceeding.
Data from PCRs may help determine future treatments, trends, research, and quality improvement. continued

Chapter Review Your report should “paint a picture” of your patient and their condition, accurately describing your contact with the patient throughout the call.

Remember Emergency medical communication comes in many forms and is essential to team-based patient care. The medical radio report is structured to present pertinent facts about the patient without providing more detail than necessary. continued

Remember A proper verbal report will include the chief complaint, any history that was not given previously, additional treatment given, and additional vital signs taken en route. continued

Remember Interpersonal communication is often challenging in EMS. Adopting best practices can improve communication capabilities significantly. Confidentiality, patient refusals, and falsification of records are all-important legal concepts that an EMT must consider when documenting a call.

Questions to Consider How can you improve your interpersonal communication with patients and team members? What is “objective” and “subjective” information in the narrative portion of the PCR? Talking Points: Students should evaluate their own communication characteristics and follow the pointers in the chapter to improve their techniques. They might want to do this with a partner. Sometimes the boundary between objective and subjective may be unclear. Is a fact verifiable, or does it rest on someone’s opinion? Remind students to err on the side of complete documentation.

Critical Thinking Organize this random information, and present a radio report to the hospital. Chest pain radiating to shoulder 56 years old Oxygen applied at 15 L/minute via nonrebreather Alert and oriented Female continued

Critical Thinking Came on 20 minutes ago while mowing lawn
History of high blood pressure and diabetes Pulse 86, respirations 22, skin cool and moist, blood pressure 110/66, SpO2 96% Oxygen relieved pain slightly Denies difficulty breathing Requesting orders from medical direction You are on Community BLS Ambulance 4 continued

Critical Thinking Lung sounds equal on both sides
Placed in a position of comfort ETA 20 minutes continued

Critical Thinking Write a narrative report for the same call. Will you use different information?

Please visit Resource Central on www. bradybooks
Please visit Resource Central on to view additional resources for this text. Please visit our web site at and click on the mykit links to access content for this text. Under Instructor Resources, you will find curriculum information, lesson plans, PowerPoint slides, TestGen, and an electronic version of this instructor’s edition. Under Student Resources, you will find quizzes, critical thinking scenarios, weblinks, animations, and videos related to this chapter—and much more.

Introduction to Emergency Medical Care 1

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