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Chapter 4 Communications and documentation (How to write a narrative…
Chapter 4 Communications and documentation
Communication
Documentation
Therapeutic communication
Facilitation
Silence
Reflection
Empathy
Clarifacation
Confrontation
Intreprataton
Explanation
Summary
Factors and strategies to consider during communication
Age
Body language
Clothing
Education
Culture
Envirnment
Eye contact
Facial expression
gender
Posture
Voice tempo
Volume
Shannon-Weaver communication model
Ethnocentrism
Cultural imposition
open-ended questions
Close ended questions
Interview Techniques to avoid
False hope
Unsolicited advice
Ask leading or biased questions
talk too much
Inturrupt the patient
use "why" questions
Use authoritative language
Speak in professional jargon
Ten Golden rules to calm and reassure a patient
Eye contact
Identify yourself
speak slowly, clearly and distinctly
Be honest,dont lie to the patient.
consider if the patient is hard of hearing positioning yourself front facing so that they are able to read your lips
Use language that the patient can understand
Allow time for the patient to answer your questions
Be careful of what you say about the patient to others
Act and speak in a calm, confident manner while caring for the patient.
be aware of your body language
Alternative ways of communicating
Communicating with children
hard of hearing or deaf
Visually impared
older patients
Communicating with other healthcare professionals
Opening information
Detailed information
History
patient response
Vital signs
other information
Written communication
Types of forms
EPCR
PCR
Continuity of care
Legal documentation
Education
Administrative information
Time
at scene
left scene
notified
arrive to receiving facility
reported
Transferd
Essential research record
Evaluation and continuous quality improvement
Chief complaint
LOC
Vitals
Innitial assesment
Pt demograpgics
How to write a narrative report
Number of patients: Record only when more than one patient is present. "This is Patient 2 of 3"
Additional help: Did you call for help?If so, state why, at what time and what time the help arrived. Was transport delayed?
NOI/MOI: Simply state
Cervical spine: State what cervical spine precautions were initiated and you might want to include why, "Due to the significant MOI"
Scene safety: Did you have to make the scene safe? If so, what did you do and why did you do it?
Initial general impression: Simply record if not already documented on the PCR
Standard precautions: Were standard precautions initiated? if so, state which precautions were used and why?
LOC: Be sure to report LOC, any changes and the times in which the changes occured.
Chief complaint: Note and quote pertinent statements made by the patient and or bystanders this includes any patient denials;"Patient denies chest pain"
Life threats:List all the interventions and how the patient responded;"Assisted ventilattions with O2 (15L/min) at 20 bpm with no changes in LOC"
ABC's :again document what you found and interventions performed
Oxygen: record if O2 was used, how it was applied and how much was administered
Primary, Secondary, patient history or reassessment: state the type of assessment used and any pertinent findings; "secondary assessment revealed unequal pupils, crepitus to the right ribs, and apparent closed fracture to the left tibia."
SAMPLE/OPQRST:note and quote any patient answers
Vital signs:your service may require you to record vital signs to the narritive portion, as well as other places in the PCR
Medical direction:Quote any orders given to you by medical control, and state who gave them.
Management and secondary injuries/ treat for shock: Report all patient interventions, at what time they were completed and how the patient responded
Receiving facility: Document the name o the facility, the area of the facility where the patient was delivered and the room number if known.
Transfer of care: Record the name of the staff member who received your report, and took over patient care as well as the time.
Reporting errors
Special reporting situations
Documenting refusal forms
Mass casualty incident
Base station Radios
base station
Channel
dedicated line
mobile and portable radios
VHF
UHF
Repeater based radio
Digital equuipment
telemetry
Cellular Telephones
Scnner
Matinance of the radios
Standing orders
Other communication equipments
Simplex:
Duplex:
Multiplex
MED Channels
Trunking
interoperable communication system
MobileData Terminal
Radio communications
Federal communication commission
Establish licensing standards and operating specifications for radio equipment used by EMS providers
Establish limitations for transmitter power output
License base stations and assign appropriate radio call signs for those situations
Monitor radio operations
Allocate specific radio frequencies for use by EMS providers
Responding to the scene
Dispatch duties
EMS Communication with Dispatch
Initial receipt of the call
En route to the call
on scene
Arrival at the hospital (or point of transfer)
Return to service
Miscellaneous
Communicating with Medical control and hospitals
Patient report
The Role of medical control
Calling medical control
Information about Special situations