1. Medical Communications and Documentation
Chapter 8
Medical Communications and Documentation

3. Objectives 8.1 List the two types of medical communications.
8.2 List the essential content that should be included in all verbal communications, using the acronym SAILER.
8.3 List the components for the following methods used to complete a PCR:
SOAP
CHEATED
continued

4. Objectives
8.4 List the characteristics of good report writing using the acronym FACTUAL-OEC. 8.5 Describe and demonstrate how to correct an error on a written report. 8.6 List two criteria that must be documented on a patient refusal. 8.7 List four injuries or crimes that a mandated reporter must report to authorities.
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5. Objectives
8.8 Demonstrate how to complete a sample patient care report with 100-percent accuracy. 8.9 Demonstrate how to provide an oral report.

6. Topics Communications Basics Verbal and Written Communications
Notes / Reports / Forms
Characteristics of Good Report Writing
Essential Content of Medical Communications
Special Circumstances

7. Communications Basics
Communication is a process in which a message is transmitted from a sender to a receiver.
It is vital that the sender and receiver have the same message.
Restatement can help ensure that the correct information has been received
Medical communication is the transfer of health care related information.
Discussion Points: A vital issue here is the accurate sending and receiving of the message. You may want to brainstorm situations where miscommunication has be encountered within or outside of the patrolling experience, including how the communications became confused, and what consequences occurred as a result. A second topic for discussion would be how to minimize the chances of miscommunication. This issue is addressed in further slides where clarity and accuracy are emphasized. The third topic here is confidentiality and HIPAA factors as noted in the text. You will have to cover the process used at your area to ensure appropriate levels of confidentiality in verbal exchanges, and the process of completing and filing written documentation.

8. Verbal Communications
Transfers information through spoken words, and may be face to face or device related
With patient / witnesses at the scene
With the first aid area via radio
With patrol help when it arrives
With personnel at the first aid area
Hand-off report
Discussion Points: It is likely that local protocols will have to be covered in all of these areas. The issues of witnesses at the scene is particularly subject to varied practices based on area management directives. At your area, how are employees who are witnesses handled? how about friends of the patient? how about friends of the “other” person who may have been involved? Does the patrol handle all witness interviews? Does area management do the interviews? Be sure your students understand their role in these situations.
Radio protocols also vary from area to area. The text mentions limiting the amount of patient information sent across the airwaves, and suggests that standard English rather than codes be used. Again, you must ensure student understanding of your area procedures.
Any communications with fellow patrollers must be professional and occur in a way that both protects the patient confidentiality, and enhances the patient’s positive experience. At some point in the training you’ll have to cover discussions between patrollers where a disagreement may be an issue. Additionally, you will have to impress upon students that their verbal communications must be clear and accurate, but not “diagnostic.”
Handing off the patient to family, friends, or EMS will also likely involve giving some verbal, or possibly written, information. Local protocols, especially for EMS interfaces, will need to be clear.
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9. Verbal Communications
Non-verbal elements may affect the message
Present essential information that is clear, concise, and organized
SAILER acronym may be used to radio patient information and request assistance
Sender verifies receiver’s accuracy
Discussion Points: This could be an opportunity to have some fun with the non-verbal elements, with the same exact words giving several different messages depending on the delivery – facial expressions, posture, voice inflection, etc. SAILER is a suggestion, your local protocols will determine how much of that information is transmitted. We have noted a second time that the receiver should be checking the information by repeating, or paraphrasing it so that the sender can verify its accuracy.

10. SAILER Sex of patient Age of patient Incident – chief complaint
Location of the accident/patient
Equipment needed
Resources needed
Discussion Points: As mentioned in the previous slide, this is a quick way to remember the basic information that may be transmitted from the hill to the patrol base during a rescue.

11. Written Communications
Documents the patient encounter and becomes a permanent record
May include informal notes as well as formal documents
Field care notes
Incident report forms
Patient care reports
Discussion Points: Reports often include the written documentation of verbal communications between patrollers, interviews with patients and witnesses, and communications with others such as family, friends, or EMS personnel. This is the first chance to discuss the importance of written elements and to begin to relate them to risk management.
continued

12. Written Communications
Accurately describe facts associated with the accident
Discussion Points: The text notes that lawsuits and other reviews of documentation often take place a year or more after the incident, and paperwork must be sufficient to be useful at those times.
continued

13. Written Communications
Copyright Edward McNamara

14. Field Care notes Taken during the rescue operation
Essential current information
May become part of other reports
Hand off report
Formal accident report
Discussion Points: Field Care notes may or may not be used depending on factors such as area procedure, severity of the incident, or preferences of the patroller(s) involved. Area procedure may also determine if the notes become attached to the other paperwork in some physical manner. Alternately, the information may be transferred to a more formal report. The content of the “essential” information will vary based on the incident, so posing some situations may be effective in familiarizing students with what should be written down at the scene.

15. Accident Report Forms
May be from NSAA, Insurance Co., Area – paper or computer generated
Record fundamental information
Patient identification
Cause of injury
Who was at the accident scene
Care given at the scene
Care given in the aid room
Further comments
Report corrections or additions
Discussion Points: Area management usually determines which formal reports are used, how they are to be filled out and reviewed, and where they go at the end of the day. Some areas may have separate forms for location, personnel, etc., and patient care information (next slide), and some may have a combined form – and they may be either paper or electronic. This will be an opportunity for you to bring the forms and procedures used at your area to share with the students. The text outlines the process of dealing with making corrections or adding information to a report, either while the patient is still in your care or at some later time. Again, you must inform the students of the procedures at your area that may differ from what is noted in the text. Area procedures may also dictate if witness statements, scene pictures, etc are a part of this document.

16. Patient Care Reports
Used to record specific info about medical care provided to the patient
“If it isn’t documented, it didn’t happen"
May be open, closed, or mixed in format
Use SOAP / CHEATED
Complete reports are part of risk management
Discussion Points: As noted with the last slide, this information may be integrated with the “other” parts of the accident report or it may be separate. It may also include a copy of, or information from, the field care notes. Accuracy and clarity have been previously mentioned, and are included later, but should probably be mentioned here as well. A discussion of the open, closed, or mixed format should refer to the form used at your area. You may also be choosing how much emphasis to be putting on the SOAP/CHEATED acronyms based on your area procedures. Here also is a second mention of the importance of written reports in the area of risk management – there is yet a third coming.
continued

17. Patient Care Reports continued
Discussion Points: This is a good opportunity to point out the important items on the report and then discuss them at length in the following slides.
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18. Patient Care Reports

19. SOAP & CHEATED Subjective Objective Assessment Plan Chief complaint
History
Examination
Assessment
Treatment
Evaluation
Disposition
Discussion notes: These should stimulate a discussion of the terms of the acronyms and their usefulness based on your area forms and procedures.

20. Characteristics of Good Report Writing
Facts
Accurate
Complete
Terms are
Unbiased
Avoid slang
Legible
Organized
Error Free
Checked
Discussion Points: This acronym can serve as a review of the chapter up to this point. This slide provides another opportunity to mention risk management. The text mentions that the reports may be subject to subpoena, and a discussion of how a report can help or hurt the case of the patrol and area may be appropriate.

21. Essential Content of Medical Communications
Age and Gender
Chief complaint
History of present illness
Past medical history
Physical exam
Impression
Treatment
Response to treatment
Discussion Points: Emphasize the importance of make sure each of these items is included in communications.

22. Special Circumstances
Refusal of care
Incidents that must be reported to authorities
Accident investigations
Discussion Notes: As with so much of this chapter, local protocols and/or laws will play an important part of these discussions. Accident investigations may be handled quite differently from area to area, and are yet another part of the risk management considerations. Students need to understand procedures and the level of involvement expected from your area management in these situations.

24. Chapter Summary
Effective medical communications is one of the hallmarks of a highly skilled OEC Technician.
Careful documentation is important both for medical and legal reasons.
Medical communications include oral communication and written documentation.
Discussion Points: Topics in this chapter have often been repeated, so there have been opportunities to do some review with previous slides. This summary will allow you to emphasize the most important issues in this topic.
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25. Chapter Summary
Breakdowns in the communication process can create misunderstandings and errors.
An oral hand-off report should take less than 60 seconds to complete.
Patients who refuse medical assistance must have the capacity to do so.
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26. Chapter Summary Thoroughly document all patient refusals.
If it isn’t documented, it didn’t happen; document reports completely and accurately.
Write good reports by being a FACTUAL OEC Technician.

33. THE END