1. Medical Communications

2. Objectives  List the two types of medical communications  List the essential content that should be included in all verbal communications, using the acronym SAILER  List the Components for the following methods used to complete a PCR:  SOAP  CHEATED  List the characteristics of good report writing using the acronym FACTUAL-OEC  Describe and demonstrate how to correct an error on a written report  List two criteria that must be documented on a patient refusal  List four injuries or crimes that a mandated reporter must report to authorities  Demonstrate how to complete a sample patient care report  Demonstrate how to provide an oral report

3. Types of Medical Communication  Oral  Talking to patients  Radio Walkie TalkiesWalkie Talkies  Written  forms

4. Oral Sailer  Sex of patient  Age of patient  Incident/chief complaint  Location  Equipment needed  Resources needed/extra patrollers

5. Incident Report Form  Picture in book (pg 273)  Patient Care report- a report that documents a patients complaints and past medical history, plus a chronological account of the examination and treatment of the patient; it is a legal document

6. Forms cont.  Subjective- chief complaint, history of present illness, past medical history  Objective- findings from physical exam and scene size up  Assessment- your general impression of what the problem is  Plan- aspects of treatment rendered to patient

7. Still forms…  Chief complaint  History-SAMPLE history  Examination- physical exam  Assessment- general impression of patient  Tall aspects of treatment rendered (includes good Samaritans)  Evaluation-changes in the patient’s condition over time  Disposition- did the patient refuse treatment? Was patient transported to higher care?

8. FACTUAL-OEC  Facts  Accurate  Complete  Terms  Unbiased  Avoid slang  Legible/legal  Organized  Error free  Checked