1. Communication and
Documentation

2. You Are the Emergency Medical Responder
Lesson 11: Communication and Documentation
You Are the Emergency Medical Responder
As the closest responders in the area, your police unit is called to the scene where an elderly woman has collapsed in front of her home. When you arrive, a neighbor tells you that the woman suddenly collapsed and tripped on the concrete step in the walkway in front of her home. She is now conscious but a little dazed, and you find that she is also very frightened and apprehensive.

3. Components of Radio Communication for EMS
Base station – hub of communication
Mobile radios and data terminals in EMR vehicles
Portable radios – handheld
Repeaters- boost the range of portable radios
Use “clear text” when talking on the radio

4. Communicating within the Emergency Communications System
Communications Center (dispatch)
9-1-1 call center
Point of contact between public and responders
All conversations are recorded
Medical Control
Orders repeated word for word
Medical Personnel
Identify yourself as an EMR

5. Communicating within the Emergency Communications System
Receiving Facility
Hospital
Who you are
How many patients arriving
Patient characteristics
Immediate history
Care provided and patients response
ETA
Mobile Phone
Cover longer distances than radio, superior sound quality, direct communication between parties

6. Interpersonal Communication
Show empathy: be understanding and culturally sensitive to the thoughts, feelings and experiences of another person
Create positive relationships:
Introduce yourself and team members
Provide information about your role
Eye level
Listen

7. Activity
You arrive at the home of an elderly couple in response to a call for assistance. The couple’s daughter called because her father, who is bedridden due to a stroke, was having difficulty breathing. The daughter is providing the information because the elderly couple speaks very little English.

8. Documentation Established by state regulations
Documenting care is as important as providing care
The record is a legal document
If you are called to court, the documentation supports your action(s)
Quality assurance practices
Final step in providing care, accurate & complete
If it’s not written down, it didn’t happen!

9. Functions of the Prehospital Care Report (PCR)
Primary function: ensures high-quality care
Other functions:
Legal document
Educational and research tool
Administrative tool – billing/reimbursment
Confidentiality – falls within HIPAA
Refusal of treatment
Falsification is a serious offence

10. Prehospital Care Report Sample
Page 207

11. Sections of the Prehospital Care Report
Run data
Patient data
Check boxes
Patient narrative
Minimum data set
Patient information gathered by EMR
Administrative information

12. Sections of the Prehospital Care Report
Run data - administrative information
Time of incident
Arrival/departure of EMS at scene
ETA of EMS to receiving facility/transfer of care
EMS unit number
EMS crew members and certifications
Address of incident

13. Sections of the Prehospital Care Report
Patient data – patient information
Legal name
Age
Gender
Birth date
Home address
Billing/insurance information
Address of place of incident
Any care provided before EMS arrival

14. Sections of the Prehospital Care Report
Check boxes
Vital signs
Chief complaint
LOC
Appearance
Respiration rate

15. Sections of the Prehospital Care Report
Patient narrative
open ended section for a written description
SAMPLE history
Chief complaint
MOI/NOI
Description of what happened? Own words

16. You Are the Emergency Responder
As you assess the elderly patient, you learn that her chief complaint is that she “blacked out” momentarily and fell. The patient is afraid that she has broken her hip. She has pain in her pelvis and is unable to move her left leg. You give a verbal update to the EMS personnel who have just arrived to take over medical care and transport the patient.
Why is it important for communication to brief and concise? What are some examples of effective interpersonal communication? Why is it important to thoroughly document your call, observations and actions?